Healthcare Provider Details

I. General information

NPI: 1922308691
Provider Name (Legal Business Name): JOHN ANTHONY MANSOUR JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 03/07/2023
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4689 US HIGHWAY 17 STE 12
FLEMING ISLAND FL
32003-4831
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 904-375-9753
  • Fax: 904-375-8380
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberOS14658
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number020005101A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: