Healthcare Provider Details

I. General information

NPI: 1144457805
Provider Name (Legal Business Name): MICHAEL MANGAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 CHARLEVOIX DR STE 100
GRAND LEDGE MI
48837-2223
US

IV. Provider business mailing address

1035 CHARLEVOIX DR STE 100
GRAND LEDGE MI
48837-2223
US

V. Phone/Fax

Practice location:
  • Phone: 517-622-6446
  • Fax:
Mailing address:
  • Phone: 517-627-2181
  • Fax: 517-622-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101018143
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101018143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: