Provider Demographics
NPI:1790839520
Name:MANGUBAT, LUIS M (MD, SC)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:M
Last Name:MANGUBAT
Suffix:
Gender:M
Credentials:MD, SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3378
Mailing Address - Country:US
Mailing Address - Phone:815-588-3866
Mailing Address - Fax:815-588-3006
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 407
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:815-588-3866
Practice Address - Fax:815-588-3006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL314530Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER