Provider Demographics
NPI:1386953180
Name:THEODORE J MANGRU ARNP INC
Entity type:Organization
Organization Name:THEODORE J MANGRU ARNP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANGRU
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:305-439-7987
Mailing Address - Street 1:731 NW 155TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1511
Mailing Address - Country:US
Mailing Address - Phone:305-439-7987
Mailing Address - Fax:305-892-6735
Practice Address - Street 1:42 COLLINS AVE
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-7314
Practice Address - Country:US
Practice Address - Phone:305-672-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2913662363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35352Medicare UPIN