Provider Demographics
NPI:1013104025
Name:CONCEPCION MANGASEP M.D., INC.
Entity type:Organization
Organization Name:CONCEPCION MANGASEP M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONCEPCION
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANGASEP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-422-2920
Mailing Address - Street 1:7661 PUERTO RICO DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1270
Mailing Address - Country:US
Mailing Address - Phone:213-422-2920
Mailing Address - Fax:818-670-7892
Practice Address - Street 1:2918 MARINE AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-3637
Practice Address - Country:US
Practice Address - Phone:310-327-1212
Practice Address - Fax:818-670-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66574174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA123853OtherLACO MENTAL HEALTH
CA00A665740Medicaid
CAH68322Medicare UPIN
CAW21234Medicare PIN