Provider Demographics
NPI:1548453285
Name:MANGLA, ADITYA (DO)
Entity type:Individual
Prefix:DR
First Name:ADITYA
Middle Name:
Last Name:MANGLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7887
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:8548 112TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1641
Practice Address - Country:US
Practice Address - Phone:718-847-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245247-1207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03493441Medicaid