Provider Demographics
NPI:1710944475
Name:MANGIAMELE, SEBASTIAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:R
Last Name:MANGIAMELE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 BEMIDJI AVE N
Mailing Address - Street 2:STE 6
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4364
Mailing Address - Country:US
Mailing Address - Phone:218-333-5694
Mailing Address - Fax:218-444-4728
Practice Address - Street 1:3801 BEMIDJI AVE N
Practice Address - Street 2:STE 6
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4364
Practice Address - Country:US
Practice Address - Phone:218-333-5694
Practice Address - Fax:218-444-4728
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43323208D00000X, 208100000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640127900Medicaid
MNF48894Medicare UPIN
MN250000664Medicare ID - Type Unspecified