Provider Demographics
NPI:1639270820
Name:MANGAN, KEVIN TIMOTHY (PT,DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:TIMOTHY
Last Name:MANGAN
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 BEA CT
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5907
Mailing Address - Country:US
Mailing Address - Phone:516-317-9593
Mailing Address - Fax:516-764-5323
Practice Address - Street 1:3941 BEA CT
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5907
Practice Address - Country:US
Practice Address - Phone:516-317-9593
Practice Address - Fax:516-764-5323
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ570A1OtherEMPIRE BLUE CROSS BLUE SHIELD
NYQ570A1OtherEMPIRE BLUE CROSS BLUE SHIELD