Healthcare Provider Details

I. General information

NPI: 1902984784
Provider Name (Legal Business Name): DONALD N. MANGRAVITE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 CURTIS ST
ALBANY CA
94706-2421
US

IV. Provider business mailing address

1114 CURTIS ST
ALBANY CA
94706-2421
US

V. Phone/Fax

Practice location:
  • Phone: 510-526-8034
  • Fax:
Mailing address:
  • Phone: 510-526-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG33076
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: