Healthcare Provider Details

I. General information

NPI: 1649474024
Provider Name (Legal Business Name): THERESA Y MANGUAL MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 HARTFORD TPK
VERNON CT
06066
US

IV. Provider business mailing address

428 HARTFORD TURNPIKE
VERNON CT
06066-4841
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-7374
  • Fax: 860-870-8686
Mailing address:
  • Phone: 860-871-7374
  • Fax: 860-870-8686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number028553
License Number StateCT

VIII. Authorized Official

Name: THERESA Y MANGUAL
Title or Position: M.D. OWNER
Credential: M.D.
Phone: 860-871-7374