Provider Demographics
NPI:1316146756
Name:AL-MANSOUR, MAZEN RAFIQUE (MBBS)
Entity type:Individual
Prefix:
First Name:MAZEN
Middle Name:RAFIQUE
Last Name:AL-MANSOUR
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:BOX 100109
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610
Mailing Address - Country:US
Mailing Address - Phone:352-265-0761
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 308
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1270
Practice Address - Country:US
Practice Address - Phone:413-794-7020
Practice Address - Fax:413-794-2670
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME144439208600000X
MA250915208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093025/AMedicaid
OHP01701404OtherRAILROAD MEDICARE
OH0171953Medicaid
OHH477570Medicare PIN
OH0171953Medicaid