Basic Information
| Provider Information | |||||||||
| NPI: | 1831393784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAY PETER MANGULABNAN MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 HALLMARK CT | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486032183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897901275 | ||||||||
| FaxNumber: | 9892494199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3170 HALLMARK CT | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486032183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897901275 | ||||||||
| FaxNumber: | 9892494199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | MANGULABNAN | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | PETER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9897901275 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301072416 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4411167 | 05 | MI | MEDICAID |