Provider Demographics
NPI:1225039522
Name:MANGALICK, GIRISH C (MD)
Entity Type:Individual
Prefix:DR
First Name:GIRISH
Middle Name:C
Last Name:MANGALICK
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 1:1623 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-2303
Mailing Address - Country:US
Mailing Address - Phone:734-284-2600
Mailing Address - Fax:734-284-2666
Practice Address - Street 1:1623 FORD AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-2303
Practice Address - Country:US
Practice Address - Phone:734-284-2600
Practice Address - Fax:734-284-2666
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-01-21
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-05-11
Provider Licenses
StateLicense IDTaxonomies
MI4301034377174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130H222940OtherBC BS OF MICHIGAN
MI3095760Medicaid
MI3095760Medicaid
MI0N97190Medicare PIN
MI3095760Medicaid