Provider Demographics
NPI:1861490310
Name:MANGANIELLO, CHARLES M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:MANGANIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0379
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:605 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURYEA
Practice Address - State:PA
Practice Address - Zip Code:18642-1325
Practice Address - Country:US
Practice Address - Phone:570-457-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037791L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013919460001Medicaid
PA001216OtherFIRST PRIORITY HEALTH
PA024946OtherFIRST PRIORITY LIFE INS C
PA020338000OtherBLACK LUNG
PA024946OtherHIGHMARK BLUE SHIELD
PA14821 E222OtherGEISINGER HEALTH PLAN
PA001216OtherFIRST PRIORITY HEALTH