Provider Demographics
NPI:1992832810
Name:MEDHAT N. MANSOUR, M.D. INC.
Entity Type:Organization
Organization Name:MEDHAT N. MANSOUR, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEDHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-1007
Mailing Address - Street 1:2105 BEVERLY BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2216
Mailing Address - Country:US
Mailing Address - Phone:213-483-1007
Mailing Address - Fax:213-483-3207
Practice Address - Street 1:2105 BEVERLY BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2216
Practice Address - Country:US
Practice Address - Phone:213-483-1007
Practice Address - Fax:213-483-3207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24055OtherMEDICAL LICENSE NUMBER
CA00A240550Medicaid
CA05D0943499OtherCLIA NUMBER
CAA24055Medicare ID - Type UnspecifiedMEDICARE PROVIDER 3
CA00A240550Medicaid