Provider Demographics
NPI:1588685895
Name:MANGOLD, MICHAEL NORBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:NORBERT
Last Name:MANGOLD
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 1:120 N MAIN ST
Mailing Address - Street 2:#120
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3376
Mailing Address - Country:US
Mailing Address - Phone:262-338-8100
Mailing Address - Fax:262-338-0405
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:#120
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3376
Practice Address - Country:US
Practice Address - Phone:262-338-8100
Practice Address - Fax:262-338-0405
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32859207P00000X
WI32859-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31843700Medicaid
WI000054100OtherMEDICARE, WPS, FQHC
WI521833OtherMEDICARE FQHC
WI31843700Medicaid
WI000054100OtherMEDICARE, WPS, FQHC
WIF15048Medicare UPIN
WIWI2049001Medicare PIN
WIWI2050001Medicare PIN