Provider Demographics
NPI:1881736452
Name:TIMBO, MAHMOOD BULKO (PA)
Entity type:Individual
Prefix:MR
First Name:MAHMOOD
Middle Name:BULKO
Last Name:TIMBO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14901 KINGSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1405
Mailing Address - Country:US
Mailing Address - Phone:818-693-4189
Mailing Address - Fax:
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:818-693-4189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15807363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ54550Medicare UPIN
CAPA15807Medicare ID - Type UnspecifiedPHYSICIAN ASSISTANT
CAPA15807Medicare ID - Type UnspecifiedNON-PHYSICIANPRACTITIONER