Provider Demographics
NPI:1356531727
Name:LUIS M MANGUBAT MD SC
Entity type:Organization
Organization Name:LUIS M MANGUBAT MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANGUBAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-588-3866
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:815-588-3866
Mailing Address - Fax:815-588-3006
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 407
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:815-588-3866
Practice Address - Fax:815-588-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL314530Medicare PIN