Provider Demographics
NPI:1487600136
Name:MANSOUR, RAFIK (MD)
Entity type:Individual
Prefix:
First Name:RAFIK
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 1:500 BROOKLINE AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-739-1151
Mailing Address - Fax:617-278-6905
Practice Address - Street 1:500 BROOKLINE AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-739-1151
Practice Address - Fax:617-278-6905
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA50201207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3055027Medicaid
MA3055027Medicaid
A57906Medicare UPIN