Healthcare Provider Details

I. General information

NPI: 1104079607
Provider Name (Legal Business Name): MANSOOR UL HAQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MANSOOR UL HAQ MD

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE STE G50
FENTON MO
63026-0562
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-4640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036.135192
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2017014864
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: