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NPI Code Detail

MEDICARE: MATTHEW MANSOUR

MEDICARE: MATTHEW MANSOUR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program11898FL

General Provider Information

NPI Number : 1558050799
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW MANSOUR
Provider Business Mailing Address
First Line : 19919 WITTENBURG
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78256-2115
Country : US
Telephone Number : 210-254-2911
Fax Number :
Provider Business Practice Location Address
First Line : 1324 LAKELAND HILLS BLVD
Second Line :
City : LAKELAND
State : FL
Zip : 33805-4543
Country : US
Telephone Number : 863-687-1100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2023
Last Update Date : 06/22/2026

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Directions to “ MATTHEW MANSOUR ” Practice Location

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