Basic Information
| Provider Information | |||||||||
| NPI: | 1770938524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANGNITZ | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 19TH STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059344696 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4370 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342791450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2016 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME144262 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | MD.36291 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.