1730259086 NPI number — DR. ANDREW J MANGANARO MD

Table of content: DR. ANDREW J MANGANARO MD (NPI 1730259086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730259086 NPI number — DR. ANDREW J MANGANARO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGANARO
Provider First Name:
ANDREW
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730259086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1821 SCHNEBLY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
XENIA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-372-1742
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 W MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-382-3364
Provider Business Practice Location Address Fax Number:
937-382-3314
Provider Enumeration Date:
11/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  35046214 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0484033 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".