Provider Demographics
NPI:1598725988
Name:MANGUAL, THERESA Y (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:Y
Last Name:MANGUAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 HARTFORD TPKE
Mailing Address - Street 2:STE 201
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4841
Mailing Address - Country:US
Mailing Address - Phone:860-871-7374
Mailing Address - Fax:860-870-8686
Practice Address - Street 1:428 HARTFORD TPKE
Practice Address - Street 2:STE 201
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4841
Practice Address - Country:US
Practice Address - Phone:860-871-7374
Practice Address - Fax:860-870-8686
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028553207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001285536Medicaid
CT001285536Medicaid
CT160001153Medicare ID - Type Unspecified