Healthcare Provider Details

I. General information

NPI: 1912966623
Provider Name (Legal Business Name): MARLENE TEJANO MANSOUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43134 DEQUINDRE RD
STERLING HTS MI
48314
US

IV. Provider business mailing address

43134 DEQUINDRE RD
STERLING HTS MI
48314
US

V. Phone/Fax

Practice location:
  • Phone: 586-739-5000
  • Fax: 586-739-5551
Mailing address:
  • Phone: 586-739-5000
  • Fax: 586-739-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301063082
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: