Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 2144 | ME |
N | 207Q00000X | Family Doctor | 2144 | ME |
NPI | 1528175312 |
---|---|
Provider Name | Kiran A Mangalam |
First Address | Waterville, ME 04901-4974 |
Second Address | Waterville, ME 04901-4974 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2006 |
Last Update Date | 31/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
432682599 | (05) | ME |
MM7302 | MEDICARE ID - GROUP (01) |