Healthcare Provider Details

I. General information

NPI: 1902841521
Provider Name (Legal Business Name): MANSOUR VINCENT MAKHLOUF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 GOLF RD SUITE 110
DES PLAINES IL
60016-1667
US

IV. Provider business mailing address

9301 GOLF RD SUITE 110
DES PLAINES IL
60016-1667
US

V. Phone/Fax

Practice location:
  • Phone: 847-297-8001
  • Fax: 847-297-8125
Mailing address:
  • Phone: 847-297-8001
  • Fax: 847-297-8125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number036064760
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: