Provider Demographics
NPI:1851523500
Name:MANSOUR, MOUHAMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUHAMAD
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-2484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:218-333-4961
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094037207R00000X
WAMD60541420207RC0000X
MN63889207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine