Basic Information
| Provider Information | |||||||||
| NPI: | 1194762914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGOLD | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | COLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S 8TH ST STE 480W | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707530704 | ||||||||
| FaxNumber: | 2707522852 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 8TH ST STE 480W | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420712403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707530704 | ||||||||
| FaxNumber: | 2707522852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 28824 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000050544 | 01 | KY | BLUE CROSS | OTHER |