Healthcare Provider Details

I. General information

NPI: 1245670363
Provider Name (Legal Business Name): BERNARD ALBERT MANGONE D.V.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7771 N 43RD AVE
PHOENIX AZ
85051-5712
US

IV. Provider business mailing address

16021 N 7TH DR
PHOENIX AZ
85023-4437
US

V. Phone/Fax

Practice location:
  • Phone: 602-841-1200
  • Fax:
Mailing address:
  • Phone: 602-695-5477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number3371
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: