Provider Demographics
NPI:1073192381
Name:MANSOUR, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
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 1:6250 TAPPAHANNOCK DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509-1527
Mailing Address - Country:US
Mailing Address - Phone:703-966-7216
Mailing Address - Fax:
Practice Address - Street 1:225 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1815
Practice Address - Country:US
Practice Address - Phone:757-452-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program