Provider Demographics
NPI:1972662567
Name:MANSOUR, RICHARD MEDHAT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MEDHAT
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 3589
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8589
Mailing Address - Country:US
Mailing Address - Phone:657-241-3600
Mailing Address - Fax:657-241-7708
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-610-7245
Practice Address - Fax:657-241-7720
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81902207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A819020Medicaid
CAP00616526OtherMEDICARE RAILROAD
CAWA81902BMedicare PIN
CAP00616526OtherMEDICARE RAILROAD