Provider Demographics
NPI:1740266352
Name:MANSOUR, WALEED (MDL)
Entity type:Individual
Prefix:
First Name:WALEED
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MDL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 S CANFIELD NILES RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4084
Mailing Address - Country:US
Mailing Address - Phone:330-953-0129
Mailing Address - Fax:330-953-0650
Practice Address - Street 1:1397 S CANFIELD NILES RD
Practice Address - Street 2:UNIT 1
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-4084
Practice Address - Country:US
Practice Address - Phone:330-953-0129
Practice Address - Fax:330-953-0650
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078230M207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH181396874-0001OtherPENNSYLVANIA MEDICAID
OH2254180Medicaid
OHP00164262OtherRAILROAD MEDICARE
OH2254180Medicaid
OHMA4071746Medicare PIN
OH181396874-0001OtherPENNSYLVANIA MEDICAID