Provider Demographics
NPI:1710281431
Name:SHAHID MANSOOR, M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SHAHID MANSOOR, M.D. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:AVOYELLES PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:RACHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-484-3899
Mailing Address - Street 1:338 MOREAU ST STE E
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2957
Mailing Address - Country:US
Mailing Address - Phone:318-253-7022
Mailing Address - Fax:318-253-7944
Practice Address - Street 1:501 MEDICAL CENTER DR STE 3A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8124
Practice Address - Country:US
Practice Address - Phone:318-484-3899
Practice Address - Fax:318-484-3887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAHID MANSOOR, MD APMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-10
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13654R208000000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty