Provider Demographics
NPI:1427094432
Name:MANSOUR, KATHLEEN ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANNE
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1640 CYPRESS RDG
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-6936
Mailing Address - Country:US
Mailing Address - Phone:662-335-1412
Mailing Address - Fax:662-332-0249
Practice Address - Street 1:1513 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3249
Practice Address - Country:US
Practice Address - Phone:662-378-9191
Practice Address - Fax:662-378-5353
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS16061207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119870Medicaid
MSF86849Medicare UPIN