Provider Demographics
NPI:1417063470
Name:MANGAHAS MEDICAL CARE, P.C.
Entity Type:Organization
Organization Name:MANGAHAS MEDICAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGAHAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-397-6903
Mailing Address - Street 1:521 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3206
Mailing Address - Country:US
Mailing Address - Phone:219-397-6903
Mailing Address - Fax:
Practice Address - Street 1:521 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3206
Practice Address - Country:US
Practice Address - Phone:219-397-6903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045012A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000280536OtherANTHEM
IN0005078527OtherAETNA
IL0090000883OtherBCBS OF ILLINOIS
IL0090000883OtherBCBS OF ILLINOIS
IN0005078527OtherAETNA
IN202470Medicare ID - Type Unspecified