Provider Demographics
NPI:1497833693
Name:MANGO, ENRICO S (MD)
Entity Type:Individual
Prefix:
First Name:ENRICO
Middle Name:S
Last Name:MANGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:290 E MAIN STREET
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-361-4802
Mailing Address - Fax:631-361-5376
Practice Address - Street 1:290 E MAIN STREET
Practice Address - Street 2:SUITE 700
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-361-4802
Practice Address - Fax:631-361-5376
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-11-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY131139207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C08620Medicare UPIN
NY331611Medicare ID - Type Unspecified