Provider Demographics
NPI:1699883082
Name:MANSOOR, IMAD M (MD)
Entity type:Individual
Prefix:DR
First Name:IMAD
Middle Name:M
Last Name:MANSOOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:42557 WOODWARD AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5206
Mailing Address - Country:US
Mailing Address - Phone:248-454-1004
Mailing Address - Fax:248-332-9489
Practice Address - Street 1:42557 WOODWARD AVE STE 110
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5206
Practice Address - Country:US
Practice Address - Phone:248-454-1004
Practice Address - Fax:248-332-9489
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301407249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4989OtherGROUP MEDICARE PTAN
MIMI4898373OtherINDIVIDUAL MEDICARE PTAN #
MI4255895Medicaid
MI1295023547OtherNPI TYPE II
MI4255895Medicaid