Provider Demographics
NPI:1962885699
Name:MANSOUR, ALAA NAIM (DPM)
Entity type:Individual
Prefix:
First Name:ALAA
Middle Name:NAIM
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 EXECUTIVE PLAZA DR
Mailing Address - Street 2:STE 101
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2793
Mailing Address - Country:US
Mailing Address - Phone:313-565-4948
Mailing Address - Fax:313-565-4989
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2793
Practice Address - Country:US
Practice Address - Phone:313-565-4948
Practice Address - Fax:313-565-4989
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002591213ES0103X
IN07001269A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013898Medicaid