Provider Demographics
NPI:1942567540
Name:AZIM, MANSOOR (MD)
Entity Type:Individual
Prefix:MR
First Name:MANSOOR
Middle Name:
Last Name:AZIM
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 1:3770 KEYSTONE AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6340
Mailing Address - Country:US
Mailing Address - Phone:951-961-8639
Mailing Address - Fax:
Practice Address - Street 1:3770 KEYSTONE AVE APT 107
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6340
Practice Address - Country:US
Practice Address - Phone:951-961-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA128143207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine