1316146756 NPI number — MAZEN RAFIQUE AL-MANSOUR M.B.B.S

Table of content: MAZEN RAFIQUE AL-MANSOUR M.B.B.S (NPI 1316146756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316146756 NPI number — MAZEN RAFIQUE AL-MANSOUR M.B.B.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AL-MANSOUR
Provider First Name:
MAZEN
Provider Middle Name:
RAFIQUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.B.B.S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316146756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 SW ARCHER RD
Provider Second Line Business Mailing Address:
BOX 100109
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-265-0761
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01107-1270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-794-7020
Provider Business Practice Location Address Fax Number:
413-794-2670
Provider Enumeration Date:
07/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME144439 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 250915 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110093025/A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01701404 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0171953 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105750600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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