Provider Demographics
NPI:1780685693
Name:PUTTANNIAH, MANGALA (MD)
Entity Type:Individual
Prefix:
First Name:MANGALA
Middle Name:
Last Name:PUTTANNIAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:91 CHENANGO BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1293
Practice Address - Country:US
Practice Address - Phone:607-648-6667
Practice Address - Fax:607-648-4141
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140415208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00435465Medicaid
F14627Medicare UPIN
NY56709HMedicare PIN