Provider Demographics
NPI:1609013036
Name:MANGONON, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MANGONON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 ROSWELL RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8836
Mailing Address - Country:US
Mailing Address - Phone:770-333-7888
Mailing Address - Fax:770-333-7889
Practice Address - Street 1:3775 ROSWELL RD
Practice Address - Street 2:SUITE 250
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8836
Practice Address - Country:US
Practice Address - Phone:770-333-7888
Practice Address - Fax:770-333-7889
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258302-12086S0105X
GA726442086S0105X
CT0504102086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCO3778Medicare PIN
NYWZWYR1Medicare PIN