Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 019032164 | IL |
Y | 213EG0000X | General Practice | 019032164 | IL |
NPI | 1003469636 |
---|---|
Provider Name | Ahmed Mansour |
First Address | Villa Park, IL 60181-1431 |
Second Address | Chicago, IL 60647-4251 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2019 |
Last Update Date | 23/07/2019 |