Basic Information
Provider Information | |||||||||
NPI: | 1093954828 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANGOLD | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 PARK ST | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | KY | ||||||||
PostalCode: | 421011759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707815111 | ||||||||
FaxNumber: | 2707800498 | ||||||||
Practice Location | |||||||||
Address1: | 201 PARK ST | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | KY | ||||||||
PostalCode: | 421011759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707815111 | ||||||||
FaxNumber: | 2707800498 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2009 | ||||||||
LastUpdateDate: | 07/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R1117 | KY | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | TP735 | KY | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 43016 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 7100084580 | 05 | KY |   | MEDICAID | P00793922 | 01 | KY | MEDICARE RAILROAD | OTHER | 000000624662 | 01 | KY | ANTHEM | OTHER |