Provider Demographics
NPI:1376605717
Name:MANGOBA, MELANCHTON ATIGA (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANCHTON
Middle Name:ATIGA
Last Name:MANGOBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6377 RIVERSIDE AVE STE B101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3133
Mailing Address - Country:US
Mailing Address - Phone:951-686-3437
Mailing Address - Fax:951-686-8155
Practice Address - Street 1:6377 RIVERSIDE AVE STE B101
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-686-3437
Practice Address - Fax:951-686-8155
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A954440Medicare PIN