Healthcare Provider Details

I. General information

NPI: 1366603169
Provider Name (Legal Business Name): RAJIV MANGLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 648
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-7586
  • Fax: 585-473-4861
Mailing address:
  • Phone: 585-275-7586
  • Fax: 585-473-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberP63813
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: