Provider Demographics
NPI:1164598843
Name:MOFIDI, MANSOUR (DO)
Entity Type:Individual
Prefix:
First Name:MANSOUR
Middle Name:
Last Name:MOFIDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2303
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2303
Mailing Address - Country:US
Mailing Address - Phone:888-664-8297
Mailing Address - Fax:412-857-3568
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0007441277OtherAETNA
CA20A7485Medicare ID - Type Unspecified
0007441277OtherAETNA