Healthcare Provider Details

I. General information

NPI: 1710917653
Provider Name (Legal Business Name): LORIS N MANSOUR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S OSPREY AVE STE A1
SARASOTA FL
34239-2933
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-7197
  • Fax: 941-917-4016
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07927200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME138977
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: