Provider Demographics
NPI:1205919644
Name:MANSOUR, MOHAMED S (PT, MS, DPT)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:S
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:PT, MS, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 GAMBREL CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1389
Mailing Address - Country:US
Mailing Address - Phone:301-617-2773
Mailing Address - Fax:240-334-4824
Practice Address - Street 1:13500 GAMBREL CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-1389
Practice Address - Country:US
Practice Address - Phone:301-617-2773
Practice Address - Fax:240-334-4824
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23820225100000X
DCPT870480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC492196Medicare PIN