Provider Demographics
NPI:1760777320
Name:MANKAL, PAVAN KUMAR (MD)
Entity type:Individual
Prefix:
First Name:PAVAN
Middle Name:KUMAR
Last Name:MANKAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4772 KATELLA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2683
Mailing Address - Country:US
Mailing Address - Phone:562-596-5552
Mailing Address - Fax:
Practice Address - Street 1:4772 KATELLA AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2683
Practice Address - Country:US
Practice Address - Phone:562-596-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128433207RG0100X
390200000X
IL036153634207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty