Provider Demographics
NPI:1851544142
Name:MANSOUR, AHMED MANSOUR (MD)
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:MANSOUR
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 1:1656 CHAMPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-624-6241
Mailing Address - Fax:315-624-6395
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-624-6241
Practice Address - Fax:315-624-6395
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD456254207V00000X
NY272455207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03787506Medicaid
PA1031257090004Medicaid
PA1031257090004Medicaid
NYJ400141516Medicare UPIN