Healthcare Provider Details

I. General information

NPI: 1447678420
Provider Name (Legal Business Name): TIFFANY MANGAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 WINN WAY
DECATUR GA
30030-2106
US

IV. Provider business mailing address

350 WINN WAY
DECATUR GA
30030-2106
US

V. Phone/Fax

Practice location:
  • Phone: 703-534-1000
  • Fax: 404-508-9640
Mailing address:
  • Phone: 404-508-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number84873
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: