Provider Demographics
NPI:1508828344
Name:MANSUR, IZZUDDIN ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:IZZUDDIN
Middle Name:ALI
Last Name:MANSUR
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 1:49 CLEVELAND ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2855
Mailing Address - Country:US
Mailing Address - Phone:931-707-8050
Mailing Address - Fax:931-707-8048
Practice Address - Street 1:49 CLEVELAND ST
Practice Address - Street 2:SUITE 220
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-2855
Practice Address - Country:US
Practice Address - Phone:931-707-8050
Practice Address - Fax:931-707-8048
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD30604208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ063406Medicaid
TN3826692Medicare ID - Type Unspecified