Provider Demographics
NPI:1588849442
Name:MANGANTI, CONRADO OBIAS JR (IDC)
Entity Type:Individual
Prefix:
First Name:CONRADO
Middle Name:OBIAS
Last Name:MANGANTI
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073B CAMPION DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4818
Mailing Address - Country:US
Mailing Address - Phone:808-257-1571
Mailing Address - Fax:808-257-2271
Practice Address - Street 1:2073B CAMPION DR
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4818
Practice Address - Country:US
Practice Address - Phone:808-257-1571
Practice Address - Fax:808-257-2271
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman