Provider Demographics
NPI:1578503116
Name:CID MANSUR, FARES A (MD)
Entity Type:Individual
Prefix:
First Name:FARES
Middle Name:A
Last Name:CID MANSUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PMB 383609
Mailing Address - Street 2:AVE TITO CASTRO SUITE 102
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-0000
Mailing Address - Country:US
Mailing Address - Phone:787-812-1210
Mailing Address - Fax:787-812-1211
Practice Address - Street 1:CALLE ACACIA EDIFICIO MICHELLE PLAZA SECTOR VILLA FLORE
Practice Address - Street 2:SUITE 106
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-0000
Practice Address - Country:US
Practice Address - Phone:787-812-1210
Practice Address - Fax:787-812-1211
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR10164207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR220220OtherPREFERRED HEALTH
PR3603OtherFIRST MEDICAL
PR8000285OtherHUMANA INSURANCE
PRM399OtherPLAN MENONITA
PR01133OtherAMERICAN HEALTH
PR602066OtherMEDICARE Y MUCHO MAS
PR2095OtherPREFERRED MEDICARE CHOICE
PR83133OtherTRIPLE S
PR8000285OtherHUMANA HEALTH PLAN
PR060853OtherCRUZ AZUL DE PR
PR37225OtherPROSSAM
GAP00160427OtherPA;METTO
PR8000285OtherHUMANA HEALTH PLAN
PR83133OtherTRIPLE S