Provider Demographics
NPI:1831143387
Name:MANGRAY, SHAMLAL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAMLAL
Middle Name:
Last Name:MANGRAY
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 1:700 CHILDRENS DR # D00651
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-5315
Mailing Address - Fax:614-355-1597
Practice Address - Street 1:700 CHILDRENS DR # D00651
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:614-722-5315
Practice Address - Fax:614-355-1597
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10583207ZP0101X, 207ZP0213X
OH35.133020207ZP0102X, 207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007010438OtherMEDICARE PTAN NUMBER: RIH PATHOLOGY GROUP# 229006187
OHH636280OtherMEDICARE PTAN
RI007010439OtherMEDICARE PTAN NUMBER: TMH PATHOLOGY GROUP# 229006185
RI7010439Medicaid
OH0286630Medicaid