Basic Information
| Provider Information | |||||||||
| NPI: | 1245491943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANSOUR | ||||||||
| FirstName: | JONATHON | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5486 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928635486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Practice Location | |||||||||
| Address1: | 14850 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914024618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187872222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 09/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 5101017820 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.