Provider Demographics
NPI:1649380221
Name:MANGIARDI, JOSEPH N (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:N
Last Name:MANGIARDI
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8530 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-2414
Mailing Address - Country:US
Mailing Address - Phone:815-654-7777
Mailing Address - Fax:815-654-7902
Practice Address - Street 1:8530 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-2414
Practice Address - Country:US
Practice Address - Phone:815-654-7777
Practice Address - Fax:815-654-7902
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006876152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37734Medicare UPIN
IL676211Medicare PIN