Provider Demographics
NPI:1699127548
Name:MANSOUR, DALIA (MD)
Entity type:Individual
Prefix:DR
First Name:DALIA
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2920
Mailing Address - Country:US
Mailing Address - Phone:586-493-8000
Mailing Address - Fax:586-493-8799
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-1302
Practice Address - Fax:135-774-6413
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-04
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110860207R00000X
GA81232208D00000X
MI43015028802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice