Provider Demographics
NPI:1336306240
Name:MANGRA, CHANDRA (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
Last Name:MANGRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHANDRA
Other - Middle Name:
Other - Last Name:JAIPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:17 SILVER PALM AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3123
Practice Address - Country:US
Practice Address - Phone:321-733-2021
Practice Address - Fax:321-727-0884
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME130034207Q00000X
NYDEA 939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019184300Medicaid