Provider Demographics
NPI:1770675357
Name:MOSLEY, MANSOOR - (MD)
Entity Type:Individual
Prefix:MR
First Name:MANSOOR
Middle Name:-
Last Name:MOSLEY
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 1:1220 HEMLOCK WAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-3650
Mailing Address - Country:US
Mailing Address - Phone:714-754-5400
Mailing Address - Fax:714-754-6836
Practice Address - Street 1:1220 HEMLOCK WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-3650
Practice Address - Country:US
Practice Address - Phone:714-754-5400
Practice Address - Fax:714-754-6836
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41405174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414050Medicaid
CA00A414050Medicaid
CAA53729Medicare UPIN