=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831181999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS B MANGAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 03/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3125 N DYSART RD
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-726-8940
-----------------------------------------------------
Fax | 602-726-8941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3125 N DYSART RD
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-726-8940
-----------------------------------------------------
Fax | 602-726-8941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 32915
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------