Provider Demographics
NPI:1063581809
Name:MANSOOR, SAMRAH (MD)
Entity type:Individual
Prefix:DR
First Name:SAMRAH
Middle Name:
Last Name:MANSOOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 N ROCK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1312
Mailing Address - Country:US
Mailing Address - Phone:316-440-2713
Mailing Address - Fax:316-260-6897
Practice Address - Street 1:3161 N ROCK RD
Practice Address - Street 2:SUITE C
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1312
Practice Address - Country:US
Practice Address - Phone:316-440-2713
Practice Address - Fax:316-260-6897
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-31546207Q00000X
MO2006038458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO969173888Medicare PIN
MO207278201Medicaid