Provider Demographics
NPI:1730186594
Name:MANSOUR, CHAD H (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:H
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHADI
Other - Middle Name:
Other - Last Name:MANSOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-1959
Mailing Address - Country:US
Mailing Address - Phone:989-839-1644
Mailing Address - Fax:989-839-3029
Practice Address - Street 1:4000 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-1959
Practice Address - Country:US
Practice Address - Phone:989-839-1644
Practice Address - Fax:989-839-3029
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I35568Medicare UPIN