Provider Demographics
NPI:1861446841
Name:KHALILI, MANOUTCHER (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOUTCHER
Middle Name:
Last Name:KHALILI
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 1:4111 VANALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-5516
Mailing Address - Country:US
Mailing Address - Phone:818-757-7246
Mailing Address - Fax:310-323-0216
Practice Address - Street 1:1146 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3538
Practice Address - Country:US
Practice Address - Phone:323-428-9999
Practice Address - Fax:310-323-0216
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52178AMedicare PIN
CAF68057Medicare UPIN
CAA52178Medicare PIN