=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891923181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARISH MANGIPUDI D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2009
-----------------------------------------------------
Last Update Date | 09/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9330 MEDICAL PLAZA DR
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-847-3010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 743070
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-560-4304
-----------------------------------------------------
Fax | 864-560-4413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | DO4761
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------