Provider Demographics
NPI:1083751390
Name:MANGOLD, WESTON R (OD)
Entity Type:Individual
Prefix:DR
First Name:WESTON
Middle Name:R
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7152 QUARTERHORSE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-7784
Mailing Address - Country:US
Mailing Address - Phone:937-321-1033
Mailing Address - Fax:937-399-8160
Practice Address - Street 1:1275 E 2ND ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005
Practice Address - Country:US
Practice Address - Phone:937-704-0809
Practice Address - Fax:937-704-0820
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT97126Medicare UPIN
OHT97126Medicare UPIN