Provider Demographics
NPI:1427110956
Name:MANGAS, MICHAEL DRACH (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DRACH
Last Name:MANGAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-3610
Mailing Address - Country:US
Mailing Address - Phone:812-376-8754
Mailing Address - Fax:
Practice Address - Street 1:2475 COTTAGE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-4476
Practice Address - Country:US
Practice Address - Phone:812-372-7782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001786152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100051800AMedicaid
IN054300AMedicare UPIN