Provider Demographics
NPI:1093100620
Name:MANGAM, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MANGAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 TWAITS RD
Mailing Address - Street 2:
Mailing Address - City:TOWACO
Mailing Address - State:NJ
Mailing Address - Zip Code:07082-1223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 TWAITS RD
Practice Address - Street 2:
Practice Address - City:TOWACO
Practice Address - State:NJ
Practice Address - Zip Code:07082-1223
Practice Address - Country:US
Practice Address - Phone:973-334-1357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00304200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant