Provider Demographics
NPI:1801801279
Name:RADPARVAR, MANSOOR (MD)
Entity type:Individual
Prefix:
First Name:MANSOOR
Middle Name:
Last Name:RADPARVAR
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 1:12751 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5800
Mailing Address - Country:US
Mailing Address - Phone:714-636-7852
Mailing Address - Fax:
Practice Address - Street 1:12751 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-5800
Practice Address - Country:US
Practice Address - Phone:714-636-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50959174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C509590Medicaid
CAC50959OtherSTATE LICENSE