Provider Demographics
NPI:1598012759
Name:MANGUERRA, MARK CONSTANTINE CRISTOBAL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK CONSTANTINE
Middle Name:CRISTOBAL
Last Name:MANGUERRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:24035 THREE NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-4871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24035 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-4871
Practice Address - Country:US
Practice Address - Phone:301-373-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0079070207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease