Provider Demographics
NPI:1053490920
Name:KHAN, MANSOOR (MD)
Entity Type:Individual
Prefix:DR
First Name:MANSOOR
Middle Name:
Last Name:KHAN
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 7077
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-7077
Mailing Address - Country:US
Mailing Address - Phone:847-952-7181
Mailing Address - Fax:847-437-8824
Practice Address - Street 1:800 BIESTERFIELD RD # 407
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3311
Practice Address - Country:US
Practice Address - Phone:847-952-7181
Practice Address - Fax:847-437-8824
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364302965OtherTAX IDENTIFICATION NUMBER
IL110189123OtherRAILROAD MEDICARE
ILG41460Medicare UPIN
IL364302965OtherTAX IDENTIFICATION NUMBER