Provider Demographics
NPI:1902105745
Name:MARLON G MANGAHAS MD LLC
Entity Type:Organization
Organization Name:MARLON G MANGAHAS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGAHAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-942-2223
Mailing Address - Street 1:11477 OLDE CABIN RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7130
Mailing Address - Country:US
Mailing Address - Phone:314-997-5208
Mailing Address - Fax:314-997-5368
Practice Address - Street 1:11477 OLDE CABIN RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7130
Practice Address - Country:US
Practice Address - Phone:314-997-5208
Practice Address - Fax:314-997-5368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070062962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty