Provider Demographics
NPI:1063516235
Name:MANSOUR, CRAIG S (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:S
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 N BRENT ST
Mailing Address - Street 2:STE 301
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003
Mailing Address - Country:US
Mailing Address - Phone:805-653-0101
Mailing Address - Fax:805-641-0434
Practice Address - Street 1:100 N BRENT ST
Practice Address - Street 2:STE 301
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-648-2763
Practice Address - Fax:805-653-5639
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA82165207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA82165OtherSTATE OF CA
CA00WA82165AMedicaid
CAA82165OtherSTATE OF CA
WA82165AMedicare ID - Type Unspecified