Provider Demographics
NPI:1285693358
Name:MANGAS, JEROLD J (MD)
Entity type:Individual
Prefix:DR
First Name:JEROLD
Middle Name:J
Last Name:MANGAS
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 1:1950 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6008
Mailing Address - Country:US
Mailing Address - Phone:480-969-1446
Mailing Address - Fax:480-464-8652
Practice Address - Street 1:1950 S COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6008
Practice Address - Country:US
Practice Address - Phone:480-969-1446
Practice Address - Fax:480-464-8652
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11635174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z6143OtherHEALTHNET
AZ2Z6143OtherHEALTHNET
AZZ117370Medicare PIN