Healthcare Provider Details

I. General information

NPI: 1598847683
Provider Name (Legal Business Name): MANSOOR -- HASAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GV SONNY MONTGOMERY VAMC PHY&REHAB (117) 1500 E WOODROW WILSON DRIVE
JACKSON MS
39157
US

IV. Provider business mailing address

2002 LINCOLNSHIRE BLVD
RIDGELAND MS
39157
US

V. Phone/Fax

Practice location:
  • Phone: 601-964-3312
  • Fax: 601-364-1394
Mailing address:
  • Phone: 601-954-3312
  • Fax: 601-364-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number235719
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: