Healthcare Provider Details

I. General information

NPI: 1659529055
Provider Name (Legal Business Name): WALID MANGAL D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SE MONTEREY ROAD, SUITE #104 FLORIDA VISION INSTITUTE INC.
STUART FL
34994
US

IV. Provider business mailing address

1050 SE MONTEREY ROAD, SUITE #104 FLORIDA VISION INSTITUTE INC.
STUART FL
34994
US

V. Phone/Fax

Practice location:
  • Phone: 772-283-2020
  • Fax: 772-219-7924
Mailing address:
  • Phone: 772-283-2020
  • Fax: 772-219-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberOS12479
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberH0074109
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0102203133
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberOS12479
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: