Healthcare Provider Details

I. General information

NPI: 1861843963
Provider Name (Legal Business Name): MANSOUR GERGI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

89 BEAUMONT AVE # E-214
BURLINGTON VT
05405-1742
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-8400
  • Fax:
Mailing address:
  • Phone: 802-656-5482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLP03832
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number042.0015734
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number042-0015734
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: