Provider Demographics
NPI:1376548362
Name:MANGOLD, GARY B (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:B
Last Name:MANGOLD
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:LOCKNEY
Mailing Address - State:TX
Mailing Address - Zip Code:79241-0037
Mailing Address - Country:US
Mailing Address - Phone:806-652-3373
Mailing Address - Fax:806-652-2417
Practice Address - Street 1:320 N MAIN
Practice Address - Street 2:
Practice Address - City:LOCKNEY
Practice Address - State:TX
Practice Address - Zip Code:79241-0037
Practice Address - Country:US
Practice Address - Phone:806-652-3373
Practice Address - Fax:806-652-2417
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6135207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110500901Medicaid
TX1105000903Medicaid
TXB24603Medicare UPIN
TX110500901Medicaid