Healthcare Provider Details

I. General information

NPI: 1780685693
Provider Name (Legal Business Name): MANGALA PUTTANNIAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 CHENANGO BRIDGE RD
BINGHAMTON NY
13901-1293
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2558
US

V. Phone/Fax

Practice location:
  • Phone: 607-648-6667
  • Fax: 607-648-4141
Mailing address:
  • Phone: 607-770-0025
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number140415
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: