Basic Information
| Provider Information | |||||||||
| NPI: | 1386099901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANSOUR MOFIDI, DO, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2303 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919432303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192486451 | ||||||||
| FaxNumber: | 6193039380 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 GROSSMONT CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197406000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOFIDI | ||||||||
| AuthorizedOfficialFirstName: | MANSOUR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6192486451 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20A7485 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.