Provider Demographics
NPI:1033592035
Name:MANSUROV, ALAY (MD)
Entity type:Individual
Prefix:DR
First Name:ALAY
Middle Name:
Last Name:MANSUROV
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 1:908 W 4TH NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3894
Mailing Address - Country:US
Mailing Address - Phone:423-492-6100
Mailing Address - Fax:
Practice Address - Street 1:908 W 4TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3894
Practice Address - Country:US
Practice Address - Phone:423-492-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.067089207R00000X
WI72453-20207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ043373Medicaid
389016OtherAMERICAN BOARD OF INTERNAL MEDICINE/HEMATOLOGY AND ONCOLOGY