Provider Demographics
NPI:1326196312
Name:KHAN, MANSURUR R (MD)
Entity Type:Individual
Prefix:
First Name:MANSURUR
Middle Name:R
Last Name:KHAN
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 1:1940 N ORANGE GROVE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3002
Mailing Address - Country:US
Mailing Address - Phone:909-524-1940
Mailing Address - Fax:
Practice Address - Street 1:1940 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3002
Practice Address - Country:US
Practice Address - Phone:909-524-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I06749Medicare UPIN