Provider Demographics
NPI:1750925624
Name:MANSUR, GREGORY ALISSON (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALISSON
Last Name:MANSUR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8949 W 50TH LN UNIT 3
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-4445
Mailing Address - Country:US
Mailing Address - Phone:786-543-8414
Mailing Address - Fax:
Practice Address - Street 1:460 S VANCE ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3305
Practice Address - Country:US
Practice Address - Phone:303-209-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist