Provider Demographics
NPI:1881712008
Name:MANSOUR, ISSAM NABEEH (DPM)
Entity type:Individual
Prefix:DR
First Name:ISSAM
Middle Name:NABEEH
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39445 NORTHWIND CT
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-3932
Mailing Address - Country:US
Mailing Address - Phone:248-888-9500
Mailing Address - Fax:
Practice Address - Street 1:38525 8 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1012
Practice Address - Country:US
Practice Address - Phone:248-888-9504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002177213ES0103X
MI590100217213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6164970001Medicare NSC