Provider Demographics
NPI:1568464949
Name:MANGROLA, RAJENDRASINH P (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJENDRASINH
Middle Name:P
Last Name:MANGROLA
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 1:4600 MILITARY TRAIL
Mailing Address - Street 2:SUITE 206
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-4812
Mailing Address - Country:US
Mailing Address - Phone:561-691-1400
Mailing Address - Fax:561-691-1423
Practice Address - Street 1:4600 MILITARY TRAIL
Practice Address - Street 2:SUITE 206
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-4812
Practice Address - Country:US
Practice Address - Phone:561-691-1400
Practice Address - Fax:561-691-1423
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMEOO518392084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062125100Medicaid
FL65-0471736OtherTIN
FL062125100Medicaid
FL65-0471736OtherTIN