Provider Demographics
NPI:1023490828
Name:MANGIARDI, MARIO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MANGIARDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5473
Mailing Address - Country:US
Mailing Address - Phone:707-699-6100
Mailing Address - Fax:
Practice Address - Street 1:1900 S MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5473
Practice Address - Country:US
Practice Address - Phone:707-699-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1536172084N0400X, 2084P0804X
PAMT2096212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry