Provider Demographics
NPI:1104079607
Name:HAQ, MANSOOR UL (MD)
Entity type:Individual
Prefix:DR
First Name:MANSOOR
Middle Name:UL
Last Name:HAQ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MANSOOR UL
Other - Middle Name:
Other - Last Name:HAQ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 BOWLES AVE STE G50
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-0562
Practice Address - Country:US
Practice Address - Phone:636-496-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.135192207RH0003X
390200000X
MO2017014864207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification