Basic Information
Provider Information | |||||||||
NPI: | 1922334911 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DR WESTON R MANGOLD, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7152 QUARTERHORSE DR | ||||||||
Address2: |   | ||||||||
City: | SPRINGBORO | ||||||||
State: | OH | ||||||||
PostalCode: | 450667784 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373211033 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1274 E 2ND ST | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 450051994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9377040809 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2009 | ||||||||
LastUpdateDate: | 10/26/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANGOLD | ||||||||
AuthorizedOfficialFirstName: | WESTON | ||||||||
AuthorizedOfficialMiddleName: | RAY | ||||||||
AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
AuthorizedOfficialTelephone: | 9373211033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4122 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 2841590 | 05 | OH |   | MEDICAID |