Provider Demographics
NPI:1922308691
Name:MANSOUR, JOHN ANTHONY JR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:MANSOUR
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:4689 US HIGHWAY 17 STE 12
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4831
Practice Address - Country:US
Practice Address - Phone:904-375-9753
Practice Address - Fax:904-375-8380
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS14658207XX0801X
IN020005101A207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS14658OtherFL MEDICAL LICENSE
FLFM9376864OtherFL DEA