Basic Information
Provider Information
NPI: 1003804766
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANGULABNAN
FirstName: RAY
MiddleName: PETER
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X4301072416MIY Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
730737401 AETNA US HEALTHCAREOTHER
099207101 HEALTH PLUS OF MIOTHER
0N4819001 WISCONSIN PHYS SERVICESOTHER
P25942F01 BLUE CARE NETWORKOTHER
MOLINA01MIQMXPR0027616OTHER
110730434201 BCBS OF MIOTHER
441116701 MEDICAL SERVICES ADMINOTHER
441116705MI MEDICAID
730737401 AETNAOTHER
01068384105001 COMM CHOICE CARE SOURCEOTHER
N4819000101MIMEDICAREOTHER


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