Provider Demographics
NPI:1689671877
Name:MANGOLD, TERRY S (OD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:S
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 CHANDELL ST
Mailing Address - Street 2:KEYSER
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-2012
Mailing Address - Country:US
Mailing Address - Phone:304-788-5961
Mailing Address - Fax:304-788-5961
Practice Address - Street 1:1405 CHANDELL ST
Practice Address - Street 2:KEYSER
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2012
Practice Address - Country:US
Practice Address - Phone:304-788-5961
Practice Address - Fax:304-788-5961
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV718-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550607791OtherTAX ID #
WV0150688000Medicaid
WV257851OtherMAMSI HEALTH INSURANCE
WV257851OtherMAMSI HEALTH INSURANCE
WV9180001Medicare ID - Type Unspecified