Provider Demographics
NPI:1497965008
Name:MANSANO, ROY
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:MANSANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CARSON ST
Mailing Address - Street 2:BOX 480
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90509
Mailing Address - Country:US
Mailing Address - Phone:310-222-5026
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 480
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84716207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAM050376OtherGROUP
CAW14940OtherGROUP
CAAR841ZMedicare PIN
CAWA847168Medicare PIN