Provider Demographics
NPI:1053301747
Name:MANSOOR, SHAHID (MD)
Entity Type:Individual
Prefix:
First Name:SHAHID
Middle Name:
Last Name:MANSOOR
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:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2329
Mailing Address - Country:US
Mailing Address - Phone:928-342-6500
Mailing Address - Fax:928-342-6863
Practice Address - Street 1:11518 N FRONTAGE RD STE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-8994
Practice Address - Country:US
Practice Address - Phone:928-342-6500
Practice Address - Fax:928-342-6863
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ69449207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME221810099Medicaid
MEP00051895Medicare PIN
MEMM7058Medicare PIN
G70552Medicare UPIN