Provider Demographics
NPI:1881670404
Name:NATHOO, MANSUR ISMAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANSUR
Middle Name:ISMAIL
Last Name:NATHOO
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 1:15414 PINENUT BAY CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77059-3297
Mailing Address - Country:US
Mailing Address - Phone:281-338-2290
Mailing Address - Fax:281-338-6728
Practice Address - Street 1:1300 BAY AREA BLVD
Practice Address - Street 2:B150-12
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2505
Practice Address - Country:US
Practice Address - Phone:281-338-2290
Practice Address - Fax:281-338-6728
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1969207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00SJ65OtherMEDICARE
TX10016466OtherAMERIGROUP
TX133459102Medicaid
TX133459105Medicaid
TX060002186OtherRAILROAD MEDICARE
TX060002186OtherRAILROAD MEDICARE
TX133459102Medicaid