Provider Demographics
NPI:1023058302
Name:AHMED, MANSOOR (MD)
Entity type:Individual
Prefix:
First Name:MANSOOR
Middle Name:
Last Name:AHMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 LEXINGTON RD STE A-B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7923
Mailing Address - Country:US
Mailing Address - Phone:859-623-5500
Mailing Address - Fax:833-249-5207
Practice Address - Street 1:2130 LEXINGTON RD STE A-B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-7923
Practice Address - Country:US
Practice Address - Phone:859-623-5500
Practice Address - Fax:833-249-5207
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40119207RS0010X
KY7100065040207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000598642OtherANTHEM INDIVIDUAL #
KY7100065040Medicaid
786409OtherAETNA PIN#
KYI23978Medicare UPIN
KY000000598642OtherANTHEM INDIVIDUAL #