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General NPI Number Information
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NPI Number | 1558387209
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Entity Type | Organization
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Legal Business Name | LUTHER MANGOBA, MD INC.
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 07/03/2014
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Provider Practice Location Address
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Address Line | 9041 MAGNOLIA AVE SUITE 008
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City | RIVERSIDE
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State | CA
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Zip | 92503-3900
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Country | US
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Telephone | 951-687-0004
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Fax | 951-687-0080
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Provider Business Mailing Address
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Address Line | 9041 MAGNOLIA AVE SUITE 008
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City | RIVERSIDE
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State | CA
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Zip | 92503-3900
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Country | US
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Telephone | 951-687-0004
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Fax | 951-687-0080
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LUTHER MANGOBA
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Credential | M.D.
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Telephone | 951-687-0004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 05D1038270
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License Number State | CA
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