Provider Demographics
NPI:1861441701
Name:MANGASEP, CONCEPCION R (M D)
Entity Type:Individual
Prefix:
First Name:CONCEPCION
Middle Name:R
Last Name:MANGASEP
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7661 PUERTO RICO DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1270
Mailing Address - Country:US
Mailing Address - Phone:213-422-2920
Mailing Address - Fax:818-670-7892
Practice Address - Street 1:7661 PUERTO RICO DR
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1270
Practice Address - Country:US
Practice Address - Phone:213-422-2920
Practice Address - Fax:818-670-7892
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA665742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA123853OtherLACO MENTAL HEALTH
CA00A665740Medicaid
CA00A665740Medicaid
CAWA66574AMedicare PIN