Healthcare Provider Details

I. General information

NPI: 1912975236
Provider Name (Legal Business Name): KADIR MANSUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2397
JACKSONVILLE FL
32258
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-0670
  • Fax: 904-296-0698
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-619-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME92847
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME92847
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: