Provider Demographics
NPI:1811078207
Name:MANSOUR, HAYTHAM (DPM)
Entity type:Individual
Prefix:DR
First Name:HAYTHAM
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-0711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19255 EVERETT LN
Practice Address - Street 2:SUITE B
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448
Practice Address - Country:US
Practice Address - Phone:630-656-3171
Practice Address - Fax:630-657-0131
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001118A213ES0103X
IL016005301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00920915OtherRAILROAD MEDICARE
INM400038239Medicare PIN
INP00920915OtherRAILROAD MEDICARE