Provider Demographics
NPI:1821510504
Name:MANZOOR, SIDRA
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:MANZOOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3328
Mailing Address - Country:US
Mailing Address - Phone:847-316-4000
Mailing Address - Fax:
Practice Address - Street 1:4010 AERIAL WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9757
Practice Address - Country:US
Practice Address - Phone:541-687-6349
Practice Address - Fax:541-242-8361
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD197544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program