Provider Demographics
NPI:1225177074
Name:KHALIFA MANSOUR, MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KHALIFA MANSOUR, MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALIFA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-862-1134
Mailing Address - Street 1:8043 2ND ST
Mailing Address - Street 2:#105
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3621
Mailing Address - Country:US
Mailing Address - Phone:562-862-1134
Mailing Address - Fax:562-861-9895
Practice Address - Street 1:8043 2ND ST
Practice Address - Street 2:#105
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3621
Practice Address - Country:US
Practice Address - Phone:562-862-1134
Practice Address - Fax:562-861-9895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA478732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A478730Medicaid
CAF80591Medicare UPIN
CAA47873Medicare ID - Type Unspecified
CAHA47873BMedicare ID - Type Unspecified
CAHA47873AMedicare ID - Type Unspecified
CAHA47873Medicare ID - Type Unspecified