Provider Demographics
NPI:1558422931
Name:MANZOOR, RABIA (MD)
Entity Type:Individual
Prefix:
First Name:RABIA
Middle Name:
Last Name:MANZOOR
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 1:17051 SIERRA LAKES PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1274
Mailing Address - Country:US
Mailing Address - Phone:909-428-2040
Mailing Address - Fax:909-428-2191
Practice Address - Street 1:17051 SIERRA LAKES PKWY
Practice Address - Street 2:STE 101
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1274
Practice Address - Country:US
Practice Address - Phone:909-428-2040
Practice Address - Fax:909-428-2191
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361211052080A0000X
IN01059273A2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200479440Medicaid
IL553180OtherMEDICARE GROUP NUMBER
IL553180001Medicare PIN
INI13142Medicare UPIN
IN200479440Medicaid