Healthcare Provider Details

I. General information

NPI: 1750316295
Provider Name (Legal Business Name): JEFFREY LAWRENCE MANSOOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W ACACIA ST
STOCKTON CA
95203-2405
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 209-956-7725
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG39910
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG39910
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG39910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: