Provider Demographics
NPI:1013093889
Name:MANGO, MARTIN NEAL (MD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:NEAL
Last Name:MANGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2723
Mailing Address - Country:US
Mailing Address - Phone:716-631-0834
Mailing Address - Fax:716-631-0880
Practice Address - Street 1:1825 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2723
Practice Address - Country:US
Practice Address - Phone:716-631-0834
Practice Address - Fax:716-631-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0406049OtherINDEPENDANT HEALTH
NY000506421002OtherCOMMUNITY BLUE
NY00010369701OtherUNNIVERA
NYB35998Medicare UPIN
NY00010369701OtherUNNIVERA