Provider Demographics
NPI:1477565828
Name:NEJADRASOOL, MANSOUR (DPM)
Entity Type:Individual
Prefix:
First Name:MANSOUR
Middle Name:
Last Name:NEJADRASOOL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 SHERMAN WAY STE 230
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2291
Mailing Address - Country:US
Mailing Address - Phone:818-784-8420
Mailing Address - Fax:818-785-0028
Practice Address - Street 1:14600 SHERMAN WAY STE 230
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-784-8420
Practice Address - Fax:818-785-0028
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4452213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6445430003OtherNORIDIAN SECOND PTAN FOR VAN NUYS CLINIC
CA6445430003OtherNORIDIAN SECOND PTAN FOR VAN NUYS CLINIC
CAU66780Medicare UPIN
CAE4452Medicare ID - Type Unspecified