=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780685693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANGALA PUTTANNIAH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2005
-----------------------------------------------------
Last Update Date | 11/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 91 CHENANGO BRIDGE RD
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13901-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-648-6667
-----------------------------------------------------
Fax | 607-648-4141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 346 GRAND AVE
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13790-2558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-770-0025
-----------------------------------------------------
Fax | 607-729-3982
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 140415
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------