Healthcare Provider Details

I. General information

NPI: 1801861935
Provider Name (Legal Business Name): ALOYSIUS T MANGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

IV. Provider business mailing address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-6018
  • Fax: 706-638-5990
Mailing address:
  • Phone: 706-638-6018
  • Fax: 706-638-5990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15023
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: