Provider Demographics
NPI:1528041894
Name:MANGOBA, LUTHER (MD)
Entity Type:Individual
Prefix:DR
First Name:LUTHER
Middle Name:
Last Name:MANGOBA
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 1:9041 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 008
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3900
Mailing Address - Country:US
Mailing Address - Phone:951-687-0004
Mailing Address - Fax:951-687-0080
Practice Address - Street 1:9041 MAGNOLIA AVE
Practice Address - Street 2:SUITE 008
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3900
Practice Address - Country:US
Practice Address - Phone:951-687-0004
Practice Address - Fax:951-687-0080
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A775740Medicaid
CAA77574OtherSTATE LICENCSE
CA00A775740Medicaid
CAA77574OtherSTATE LICENCSE