Healthcare Provider Details

I. General information

NPI: 1295766475
Provider Name (Legal Business Name): NEIL BRIAN MANSDORF D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N TUSTIN ST
ORANGE CA
92867-7611
US

IV. Provider business mailing address

555 N TUSTIN ST
ORANGE CA
92867-7611
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-0040
  • Fax: 714-633-0045
Mailing address:
  • Phone: 714-633-0040
  • Fax: 714-633-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE4222
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberE4222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: