Provider Demographics
NPI:1902043193
Name:MANSOUR MOFIDI, D.O.,INC
Entity Type:Organization
Organization Name:MANSOUR MOFIDI, D.O.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANSOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFIDI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-770-0010
Mailing Address - Street 1:PO BOX 2303
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2303
Mailing Address - Country:US
Mailing Address - Phone:619-770-0010
Mailing Address - Fax:619-425-5869
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-770-0010
Practice Address - Fax:619-425-5869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0A7485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A7485Medicare PIN