Provider Demographics
NPI:1922334911
Name:DR WESTON R MANGOLD, LLC
Entity Type:Organization
Organization Name:DR WESTON R MANGOLD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WESTON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MANGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-321-1033
Mailing Address - Street 1:7152 QUARTERHORSE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-7784
Mailing Address - Country:US
Mailing Address - Phone:937-321-1033
Mailing Address - Fax:
Practice Address - Street 1:1274 E 2ND ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-1994
Practice Address - Country:US
Practice Address - Phone:937-704-0809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2841590Medicaid
OHT97126Medicare UPIN
OHMA0666403Medicare PIN