Provider Demographics
NPI:1205868114
Name:MANGRAVITI, JOSEPH J (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:MANGRAVITI
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 1:1305 REDMOND CIR NW
Mailing Address - Street 2:BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1345
Mailing Address - Country:US
Mailing Address - Phone:706-295-6285
Mailing Address - Fax:
Practice Address - Street 1:1305 REDMOND CIR NW
Practice Address - Street 2:BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1345
Practice Address - Country:US
Practice Address - Phone:706-295-6285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23184208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F12960Medicare UPIN
11BDDWXMedicare ID - Type Unspecified