Healthcare Provider Details

I. General information

NPI: 1306894555
Provider Name (Legal Business Name): SAMUEL MANSOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 SOUTH MAIN ST
PONTOTOC MS
38863
US

IV. Provider business mailing address

176 SOUTH MAIN ST
PONTOTOC MS
38863
US

V. Phone/Fax

Practice location:
  • Phone: 662-488-7640
  • Fax: 662-488-7675
Mailing address:
  • Phone: 662-488-7640
  • Fax: 662-488-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9152
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: