Provider Demographics
NPI:1528242724
Name:MANSEL, JOHN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:MANSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:KEITH
Other - Last Name:MANSEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2500 N STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5602
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5602
Practice Address - Fax:601-984-6439
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08768207RH0002X
MN27278207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08768OtherFREE CLINIC
MS00115528Medicaid
IAENROLLEDMedicaid
MNP01064280OtherMEDICARE RAILROAD
MNENROLLEDMedicaid
MNENROLLEDMedicaid
MN290000725Medicare PIN