Provider Demographics
NPI:1003881764
Name:MANGANIELLO, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:MANGANIELLO
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 1:479 BUCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3739
Mailing Address - Country:US
Mailing Address - Phone:860-644-5011
Mailing Address - Fax:860-644-4833
Practice Address - Street 1:479 BUCKLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3739
Practice Address - Country:US
Practice Address - Phone:860-644-5011
Practice Address - Fax:860-644-4833
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035387207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010035387CT01OtherBLUE CROSS
CT035387OtherCONNECTICARE
CT0005955242OtherAETNA
CTP405022OtherOXFORD
CT4216629Medicaid
CTOV8008OtherHEALTHNET
CT4216629Medicaid