Provider Demographics
NPI:1427281641
Name:MANSOUR, KHALED (MD)
Entity type:Individual
Prefix:
First Name:KHALED
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 1:131 MEDICAL PARK RD STE 303
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8525
Mailing Address - Country:US
Mailing Address - Phone:704-660-2617
Mailing Address - Fax:704-660-4107
Practice Address - Street 1:131 MEDICAL PARK RD STE 303
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8525
Practice Address - Country:US
Practice Address - Phone:704-660-2617
Practice Address - Fax:704-660-4107
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101259449207RC0000X, 207RI0011X
NC2023-03505207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty