Provider Demographics
NPI:1821408790
Name:MANSOOR, CANDICE ANN (MD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ANN
Last Name:MANSOOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:ANN
Other - Last Name:ATTISHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15125 22 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4406
Mailing Address - Country:US
Mailing Address - Phone:586-532-0599
Mailing Address - Fax:
Practice Address - Street 1:15125 22 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-532-0599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301105691208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program