Basic Information
| Provider Information | |||||||||
| NPI: | 1427110956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGAS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DRACH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 LAKESIDE DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472033610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123768754 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2475 COTTAGE AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472014476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123727782 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 09/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001786 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 100051800A | 05 | IN | MEDICAID |