Healthcare Provider Details

I. General information

NPI: 1578503116
Provider Name (Legal Business Name): FARES A CID MANSUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE ACACIA EDIFICIO MICHELLE PLAZA SECTOR VILLA FLORE SUITE 106
PONCE PR
00716-0000
US

IV. Provider business mailing address

PMB 383609 AVE TITO CASTRO SUITE 102
PONCE PR
00716-0000
US

V. Phone/Fax

Practice location:
  • Phone: 787-812-1210
  • Fax: 787-812-1211
Mailing address:
  • Phone: 787-812-1210
  • Fax: 787-812-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number10164
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: