Basic Information
| Provider Information | |||||||||
| NPI: | 1003804766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGULABNAN | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 MANCHESTER DR | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486099220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897810140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3170 HALLMARK CT | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486032183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897901275 | ||||||||
| FaxNumber: | 9892494199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 12/28/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301072416 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7307374 | 01 | AETNA US HEALTHCARE | OTHER | N48190001 | 01 | MI | MEDICARE | OTHER | 1107304342 | 01 | BCBS OF MI | OTHER | 0992071 | 01 | HEALTH PLUS OF MI | OTHER | 4411167 | 01 | MEDICAL SERVICES ADMIN | OTHER | 4411167 | 05 | MI | MEDICAID | 7307374 | 01 | AETNA | OTHER | P25942F | 01 | BLUE CARE NETWORK | OTHER | 010683841050 | 01 | COMM CHOICE CARE SOURCE | OTHER | 0N48190 | 01 | WISCONSIN PHYS SERVICES | OTHER | MOLINA | 01 | MI | QMXPR0027616 | OTHER |