Provider Demographics
NPI:1912593922
Name:MANSUR, ISAAC D W (DC)
Entity Type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:D W
Last Name:MANSUR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 52ND ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3828
Mailing Address - Country:US
Mailing Address - Phone:262-925-9300
Mailing Address - Fax:
Practice Address - Street 1:4516 52ND ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3828
Practice Address - Country:US
Practice Address - Phone:262-925-9300
Practice Address - Fax:262-925-9300
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0000000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100146487Medicaid