Healthcare Provider Details

I. General information

NPI: 1053319962
Provider Name (Legal Business Name): MERVAT B MANSOUR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 AUER CT STE D
EAST BRUNSWICK NJ
08816-5824
US

IV. Provider business mailing address

26 GATES AVE
EAST BRUNSWICK NJ
08816
US

V. Phone/Fax

Practice location:
  • Phone: 732-257-5530
  • Fax: 732-257-5531
Mailing address:
  • Phone: 718-377-2834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number220228
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA08176800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: