Provider Demographics
NPI:1972709103
Name:MANGAN, MARTIN A (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:MANGAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 N CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5298
Mailing Address - Country:US
Mailing Address - Phone:208-220-1057
Mailing Address - Fax:208-225-4249
Practice Address - Street 1:98 N CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5298
Practice Address - Country:US
Practice Address - Phone:208-520-2809
Practice Address - Fax:208-225-4249
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-07-07
Deactivation Date:2021-06-07
Deactivation Code:
Reactivation Date:2021-07-02
Provider Licenses
StateLicense IDTaxonomies
IDO-0518207Q00000X
IDMR 0934207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMR 0934OtherSTATE LICENSE