Healthcare Provider Details

I. General information

NPI: 1558050799
Provider Name (Legal Business Name): MATTHEW MANSOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

19919 WITTENBURG
SAN ANTONIO TX
78256-2115
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1100
  • Fax:
Mailing address:
  • Phone: 210-254-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11898
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: