Provider Demographics
NPI:1902984784
Name:MANGRAVITE, DONALD N (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:N
Last Name:MANGRAVITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-2421
Mailing Address - Country:US
Mailing Address - Phone:510-526-8034
Mailing Address - Fax:
Practice Address - Street 1:1114 CURTIS ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2421
Practice Address - Country:US
Practice Address - Phone:510-526-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G330760Medicaid
CA00G330760Medicaid
00G330760Medicare ID - Type Unspecified