Provider Demographics
NPI:1023080512
Name:MIKY, MANSOUR (MD)
Entity type:Individual
Prefix:
First Name:MANSOUR
Middle Name:
Last Name:MIKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 US HIGHWAY 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082652208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2505210422OtherBLUE CROSS BLUE SHIELD MI
MI4603246Medicaid
P00151202Medicare PIN
MIH96933Medicare UPIN
MI0N90240001Medicare PIN