Basic Information
Provider Information | |||||||||
NPI: | 1821070194 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANGUAL | ||||||||
FirstName: | RAFAEL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 PAPPAS ST | ||||||||
Address2: |   | ||||||||
City: | LAREDO | ||||||||
State: | TX | ||||||||
PostalCode: | 780411705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9567958100 | ||||||||
FaxNumber: | 9567186294 | ||||||||
Practice Location | |||||||||
Address1: | 1515 PAPPAS ST | ||||||||
Address2: |   | ||||||||
City: | LAREDO | ||||||||
State: | TX | ||||||||
PostalCode: | 780411705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9567958100 | ||||||||
FaxNumber: | 9567186294 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2005 | ||||||||
LastUpdateDate: | 12/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | L0395 | TX | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 046869603 | 05 | TX |   | MEDICAID | 0010HX | 01 | TX | BLUE CROSS BLUE SHIELD OF | OTHER | 08019173 | 01 | TX | RAILROAD MEDICARE | OTHER | H27087 | 01 | MO | MERCY HEALTH PLANS | OTHER | 037596602 | 05 | TX |   | MEDICAID |