Provider Demographics
NPI:1649364126
Name:MANSOUR, JASON (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
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 1:101 S FORT LAUDERDALE BEACH BLVD
Mailing Address - Street 2:UNIT 705
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1559
Mailing Address - Country:US
Mailing Address - Phone:954-740-1505
Mailing Address - Fax:
Practice Address - Street 1:1600 S. ANDREWS AVENUE
Practice Address - Street 2:PHOENIX EMERGENCY MEDICINE OF BROWARD
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-355-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96393207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276227700Medicaid
FL276227700Medicaid