Provider Demographics
NPI:1649474024
Name:THERESA Y MANGUAL MD
Entity type:Organization
Organization Name:THERESA Y MANGUAL MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MANGUAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-871-7374
Mailing Address - Street 1:428 HARTFORD TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4841
Mailing Address - Country:US
Mailing Address - Phone:860-871-7374
Mailing Address - Fax:860-870-8686
Practice Address - Street 1:428 HARTFORD TPK
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066
Practice Address - Country:US
Practice Address - Phone:860-871-7374
Practice Address - Fax:860-870-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028553174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT160001153Medicare ID - Type UnspecifiedPROVIDER I.D. NUMBER