Provider Demographics
NPI:1073718466
Name:TIWANA, MANSOOR I (MD)
Entity Type:Individual
Prefix:
First Name:MANSOOR
Middle Name:I
Last Name:TIWANA
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:200 E CHESTNUT ST BLDG SUITE303
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-629-5552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072444A207R00000X
PAMD432054207R00000X, 208M00000X
KY44189207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1747437OtherAETNA
PA1973534OtherHIGHMARK BLUE SHIELD
PA1019486730001Medicaid
PA34935,34936,34937OtherHEALTH PARTNERS
PA1019486730003Medicaid
KY44189OtherKY LICENSE
PA2852822000OtherPERSONAL CHOICE
PA2852822000OtherKEYSTONE IBC
KY000000609439OtherANTHEM
PA30043623OtherKEYSTONE MERCY
KY7100177580Medicaid
IN01072444AOtherINDIANA LICENSE
PA1019486730002Medicaid
KY7100177580Medicaid