MEDICARE: DONNA 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
1	390200000X	Student in an Organized Health Care Education/Training Program		NY
2	1223G0001X	General Practice Dentistry	DN24732	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992368112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA MANSOUR

Provider Business Mailing Address
First Line	:	4020 SAWYER RD
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34233-1272
Country	:	US
Telephone Number	:	941-366-7475
Fax Number	:

Provider Business Practice Location Address
First Line	:	212 N MOON AVE
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33510-4422
Country	:	US
Telephone Number	:	813-689-5928
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	07/26/2022

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Directions to “ DONNA MANSOUR ” Practice Location

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