Basic Information
| Provider Information | |||||||||
| NPI: | 1033299193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANG | ||||||||
| FirstName: | GEOGE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 520112 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113520112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188868180 | ||||||||
| FaxNumber: | 7187322062 | ||||||||
| Practice Location | |||||||||
| Address1: | 13302 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113553629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861150 | ||||||||
| FaxNumber: | 7188861185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170100000X | 188903 | NY | Y | Other Service Providers | Medical Genetics, Ph.D. Medical Genetics |
ID Information
| ID | Type | State | Issuer | Description | 01663538 | 05 | NY | MEDICAID |