Provider Demographics
NPI:1194179887
Name:MANSURI, SOOHAN (MD)
Entity type:Individual
Prefix:
First Name:SOOHAN
Middle Name:
Last Name:MANSURI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 LOMITA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3950
Mailing Address - Country:US
Mailing Address - Phone:310-944-9344
Mailing Address - Fax:
Practice Address - Street 1:3640 LOMITA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3950
Practice Address - Country:US
Practice Address - Phone:310-944-9344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC193838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032455380003Medicaid