Provider Demographics
NPI:1326309154
Name:MAHMOOD, OMAR MENDOZA (PHD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:MENDOZA
Last Name:MAHMOOD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 NATIONAL BOULEVARD
Mailing Address - Street 2:SUITE 611
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4170
Mailing Address - Country:US
Mailing Address - Phone:310-273-4843
Mailing Address - Fax:310-273-5056
Practice Address - Street 1:10801 NATIONAL BOULEVARD
Practice Address - Street 2:SUITE 611
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4170
Practice Address - Country:US
Practice Address - Phone:310-273-4843
Practice Address - Fax:310-273-5056
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24715103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGH439YOtherMEDICARE ID