Provider Demographics
NPI:1215064142
Name:MANSOUR, MEDHAT (MD)
Entity type:Individual
Prefix:
First Name:MEDHAT
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 1:2105 BEVERLY BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2216
Mailing Address - Country:US
Mailing Address - Phone:213-483-1007
Mailing Address - Fax:213-483-3207
Practice Address - Street 1:2105 BEVERLY BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2216
Practice Address - Country:US
Practice Address - Phone:213-483-1007
Practice Address - Fax:213-483-3207
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24055208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24055OtherMEDICAL LICENSE NUMBER
CA00A240550Medicaid
CAA23801Medicare UPIN
CAA24055Medicare ID - Type UnspecifiedMEDICARE PROVIDER #