Provider Demographics
NPI:1174575104
Name:LAMMOGLIA, MARIO A (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:A
Last Name:LAMMOGLIA
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 1:1721 BIRMINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4082
Mailing Address - Country:US
Mailing Address - Phone:979-764-1474
Mailing Address - Fax:979-695-2789
Practice Address - Street 1:1721 BIRMINGHAM DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-4082
Practice Address - Country:US
Practice Address - Phone:979-764-1474
Practice Address - Fax:979-764-9249
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1859207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11353002Medicaid
TXG36657Medicare UPIN
TX11353002Medicaid