Provider Demographics
NPI:1538166418
Name:MANSOUR, KHALIFA (MD)
Entity type:Individual
Prefix:
First Name:KHALIFA
Middle Name:
Last Name:MANSOUR
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 1:8043 2ND ST
Mailing Address - Street 2:STE 105
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3621
Mailing Address - Country:US
Mailing Address - Phone:562-862-1134
Mailing Address - Fax:562-861-9895
Practice Address - Street 1:8043 2ND ST
Practice Address - Street 2:STE 105
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3621
Practice Address - Country:US
Practice Address - Phone:562-862-1134
Practice Address - Fax:562-861-9895
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA478732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A478730Medicaid
F80591Medicare UPIN
CA00A478730Medicaid
CAHA47873Medicare ID - Type Unspecified
CAHA47873AMedicare ID - Type Unspecified
CAHA47873BMedicare ID - Type Unspecified