Healthcare Provider Details

I. General information

NPI: 1467681486
Provider Name (Legal Business Name): ROBBIE THOMAS MANGALASSERIL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2009
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 STATE HIGHWAY 248 STE 200
BRANSON MO
65616-4186
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-4112
  • Fax: 417-335-4684
Mailing address:
  • Phone: 417-269-7241
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2015030667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: