Healthcare Provider Details

I. General information

NPI: 1710072012
Provider Name (Legal Business Name): SHAHID MANSOOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MEDICAL CENTER DR STE 3A
ALEXANDRIA LA
71301
US

IV. Provider business mailing address

501 MEDICAL CENTER DR STE 3A
ALEXANDRIA LA
71301
US

V. Phone/Fax

Practice location:
  • Phone: 318-484-3899
  • Fax: 318-484-3887
Mailing address:
  • Phone: 318-484-3899
  • Fax: 318-484-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13654 R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: