=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700237336
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVANI SANJEEV MANGOLI DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2016
-----------------------------------------------------
Last Update Date | 11/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 HAWTHORNE LN STE 100
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-2467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HANES HOUSE ROOM 378, DUMC BOX 102382 315 TRENT DRIVE
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27710-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0207X
-----------------------------------------------------
Taxonomy Name | Pediatric Hematology & Oncology Physician
-----------------------------------------------------
License Number | 2019-00440
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | UO5120
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------