Provider Demographics
NPI:1659684777
Name:MANSOOR, MARYAH (MD)
Entity type:Individual
Prefix:
First Name:MARYAH
Middle Name:
Last Name:MANSOOR
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 1:1800 N KNOXVILLE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3005
Mailing Address - Country:US
Mailing Address - Phone:309-308-0910
Mailing Address - Fax:309-308-0919
Practice Address - Street 1:1800 N KNOXVILLE AVE STE E
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3005
Practice Address - Country:US
Practice Address - Phone:309-308-0910
Practice Address - Fax:309-308-0919
Is Sole Proprietor?:No
Enumeration Date:2010-07-18
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0011382207RR0500X
390200000X
IL036172307207RR0500X
MN75524207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN75524OtherMD LICENSE