Provider Demographics
NPI:1861687485
Name:BASIL MANGRA MD PA
Entity Type:Organization
Organization Name:BASIL MANGRA MD PA
Other - Org Name:BASIL AMNGRA MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-484-6440
Mailing Address - Street 1:2518 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-2777
Mailing Address - Country:US
Mailing Address - Phone:954-484-6440
Mailing Address - Fax:954-484-0337
Practice Address - Street 1:2518 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-2777
Practice Address - Country:US
Practice Address - Phone:954-484-6440
Practice Address - Fax:954-484-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty