Basic Information
| Provider Information | |||||||||
| NPI: | 1316146756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL-MANSOUR | ||||||||
| FirstName: | MAZEN | ||||||||
| MiddleName: | RAFIQUE | ||||||||
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| Credential: | M.B.B.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | BOX 100109 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650761 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 MEDICAL CENTER DRIVE | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137947020 | ||||||||
| FaxNumber: | 4137942670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME144439 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 250915 | MA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 110093025/A | 05 | MA | MEDICAID | P01701404 | 01 | OH | RAILROAD MEDICARE | OTHER | 0171953 | 05 | OH | MEDICAID |