Provider Demographics
NPI:1881816122
Name:HOLLARMANGAM PC
Entity Type:Organization
Organization Name:HOLLARMANGAM PC
Other - Org Name:EAST VALLEY OB GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-461-1161
Mailing Address - Street 1:1450 S DOBSON ROAD
Mailing Address - Street 2:B221
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202
Mailing Address - Country:US
Mailing Address - Phone:480-461-1161
Mailing Address - Fax:480-835-1482
Practice Address - Street 1:1450 S DOBSON ROAD
Practice Address - Street 2:B221
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-461-1161
Practice Address - Fax:480-835-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27458207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF14738Medicaid
AZ522799Medicaid
AZ472366Medicaid
AZ522799Medicaid
AZ472366Medicaid
AZ109114Medicare ID - Type Unspecified