Provider Demographics
NPI:1043628589
Name:MANSOUR, WALEED (DO)
Entity Type:Individual
Prefix:
First Name:WALEED
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-2300
Mailing Address - Country:US
Mailing Address - Phone:815-971-7000
Mailing Address - Fax:
Practice Address - Street 1:8201 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74297207P00000X
IL036143374207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036143374Medicaid
WI1043628589Medicaid