Provider Demographics
NPI:1700863214
Name:MANGAN, RICHARD B (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:MANGAN
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 1:1935 BLUEGRASS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1179
Mailing Address - Country:US
Mailing Address - Phone:502-364-0033
Mailing Address - Fax:502-361-4488
Practice Address - Street 1:1935 BLUEGRASS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1179
Practice Address - Country:US
Practice Address - Phone:502-364-0033
Practice Address - Fax:502-361-4488
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003024A152W00000X
KY1403DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77014033Medicaid
IN200313540Medicaid
OH2246224Medicaid
U80115Medicare UPIN
OH2246224Medicaid
IN200313540Medicaid
INP00765026Medicare PIN
IN331420003Medicare PIN
OHP00821292Medicare PIN