Healthcare Provider Details

I. General information

NPI: 1972709103
Provider Name (Legal Business Name): MARTIN A MANGAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date: 06/07/2021
Reactivation Date: 07/02/2021

III. Provider practice location address

98 N CAMBRIDGE DR
RIGBY ID
83442-5298
US

IV. Provider business mailing address

98 N CAMBRIDGE DR
RIGBY ID
83442-5298
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-2809
  • Fax: 208-225-4249
Mailing address:
  • Phone: 208-220-1057
  • Fax: 208-225-4249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberO-0518
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0518
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: