Basic Information
| Provider Information | |||||||||
| NPI: | 1750502357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANZOOR | ||||||||
| FirstName: | FATIMAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705350191 | ||||||||
| FaxNumber: | 7705350916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/22/2011 | ||||||||
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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 | 207R00000X | 6241 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 064600 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 588865 | 01 | GA | WELLCARE | OTHER | 01401428 | 01 | GA | AMERIGROUP | OTHER | P00903602 | 01 | GA | MEDICARE RAILROAD | OTHER | 003100463A | 05 | GA | MEDICAID | 1700011 | 01 | GA | CIGNA | OTHER | 52497649 | 01 | GA | BCBS | OTHER |