Healthcare Provider Details

I. General information

NPI: 1194059600
Provider Name (Legal Business Name): MANSOOR AHMAD M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

IV. Provider business mailing address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4670
  • Fax: 309-672-4669
Mailing address:
  • Phone: 309-672-4670
  • Fax: 309-672-4669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125055157
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.128536
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: