Provider Demographics
NPI:1760851398
Name:MANSOUR, BASEM
Entity Type:Individual
Prefix:
First Name:BASEM
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BONNIE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-5108
Mailing Address - Country:US
Mailing Address - Phone:732-533-7330
Mailing Address - Fax:
Practice Address - Street 1:5607 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3317
Practice Address - Country:US
Practice Address - Phone:718-758-5220
Practice Address - Fax:718-758-5260
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist