Provider Demographics
NPI:1134205727
Name:MANGOLD, MARK RUSSELL (DC, QME)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RUSSELL
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:DC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 S WEIR CANYON RD STE 181
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-1962
Mailing Address - Country:US
Mailing Address - Phone:714-974-3930
Mailing Address - Fax:714-974-0277
Practice Address - Street 1:751 S WEIR CANYON RD STE 181
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-1962
Practice Address - Country:US
Practice Address - Phone:714-974-3930
Practice Address - Fax:714-974-0277
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21419111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU38688Medicare PIN