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General NPI Number Information
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NPI Number | 1881712008
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Entity Type | Individual
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Provider Name | ISSAM NABEEH MANSOUR DPM
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Gender | Male
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 11/09/2012
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Provider Practice Location Address
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Address Line | 38525 8 MILE RD
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City | LIVONIA
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State | MI
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Zip | 48152-1012
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Country | US
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Telephone | 248-888-9504
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Fax |
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Provider Business Mailing Address
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Address Line | 39445 NORTHWIND CT
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City | NORTHVILLE
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State | MI
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Zip | 48167-3932
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Country | US
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Telephone | 248-888-9500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 5901002177
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 590100217
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License Number State | MI
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