Basic Information
| Provider Information | |||||||||
| NPI: | 1073597241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANSOUR | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45680 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941450680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306727040 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3501 PALMER DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956828276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306727040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A86841 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | A86841 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.