Basic Information
| Provider Information | |||||||||
| NPI: | 1558422931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANZOOR | ||||||||
| FirstName: | RABIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17051 SIERRA LAKES PKWY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923361274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094282040 | ||||||||
| FaxNumber: | 9094282191 | ||||||||
| Practice Location | |||||||||
| Address1: | 17051 SIERRA LAKES PKWY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923361274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094282040 | ||||||||
| FaxNumber: | 9094282191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 036121105 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 01059273A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200479440 | 05 | IN | MEDICAID | 553180 | 01 | IL | MEDICARE GROUP NUMBER | OTHER |