Provider Demographics
NPI:1851392195
Name:MANGAN, WILLIAM THOMAS JR (DO)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:THOMAS
Last Name:MANGAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2510 LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-5669
Mailing Address - Country:US
Mailing Address - Phone:517-853-0781
Mailing Address - Fax:517-655-3979
Practice Address - Street 1:3413 WOODS EDGE DRIVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5901
Practice Address - Country:US
Practice Address - Phone:517-349-3303
Practice Address - Fax:517-349-4374
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011930207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36097OtherPTAN
MI5101011930OtherLICENSE NUMBER
MI0P19340Medicare ID - Type Unspecified
MI0C36097OtherPTAN