Provider Demographics
NPI:1679523088
Name:MANSOOR, SHADAN (MD)
Entity type:Individual
Prefix:
First Name:SHADAN
Middle Name:
Last Name:MANSOOR
Suffix:
Gender:F
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:PO BOX 164009
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-4009
Mailing Address - Country:US
Mailing Address - Phone:817-759-7000
Mailing Address - Fax:
Practice Address - Street 1:11805 SOUTH FWY STE 201
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7220
Practice Address - Country:US
Practice Address - Phone:817-551-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1226207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1736241-02Medicaid
TX1736241-01Medicaid
TX8M2993OtherBCBS
TX8D5681Medicare PIN
TX8D5680Medicare PIN