Provider Demographics
NPI:1376506873
Name:MANSOUR, SAM EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:EDWARD
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:45 N HILL DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2677
Mailing Address - Country:US
Mailing Address - Phone:540-349-1882
Mailing Address - Fax:703-738-7157
Practice Address - Street 1:45 N HILL DR STE 202
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2677
Practice Address - Country:US
Practice Address - Phone:540-349-1882
Practice Address - Fax:703-738-7157
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49545207W00000X
MDD0059626207W00000X
DCMD 34095207W00000X
VA0101233782207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037331500Medicaid
VA010107067Medicaid
VA010107024Medicaid
VA143213OtherBLUE CROSS BLUE SHIELD
VA00W140T01Medicare PIN
VA143213OtherBLUE CROSS BLUE SHIELD
VA010107067Medicaid