Provider Demographics
NPI:1063745388
Name:MANSOUR, ROOZBEH (MD)
Entity type:Individual
Prefix:
First Name:ROOZBEH
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JOHN R ST STE 615
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2022
Mailing Address - Country:US
Mailing Address - Phone:313-745-8773
Mailing Address - Fax:313-993-0595
Practice Address - Street 1:4160 JOHN R ST STE 615
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2022
Practice Address - Country:US
Practice Address - Phone:313-745-8773
Practice Address - Fax:313-993-0595
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076835A208600000X
MI4301092120208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201380480Medicaid
KY7100435160Medicaid
000001039069OtherANTHEM BCBS
000001039069OtherANTHEM BCBS