Healthcare Provider Details

I. General information

NPI: 1790938868
Provider Name (Legal Business Name): MOHAMED MANSOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 S LINDEN RD
FLINT MI
48532-3459
US

IV. Provider business mailing address

PO BOX 4085
FLINT MI
48504-0085
US

V. Phone/Fax

Practice location:
  • Phone: 407-620-3003
  • Fax:
Mailing address:
  • Phone: 407-620-3003
  • Fax: 810-471-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301092330
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301092330
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: