Healthcare Provider Details

I. General information

NPI: 1750874541
Provider Name (Legal Business Name): AHMED MAHMOUD MANSOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S CEDAR CREST BLVD
ALLENTOWN PA
18103-6202
US

IV. Provider business mailing address

8106 WOODMONT CIRCLE
MACUNGIE PA
18062
US

V. Phone/Fax

Practice location:
  • Phone: 601-402-8000
  • Fax:
Mailing address:
  • Phone: 860-333-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMT215822
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMT215822
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: