Individual
TERRY S MANGOLD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
1405 CHANDELL ST, KEYSER, KEYSER, WV 26726-2012
(304) 788-5961
(304) 788-5961
Mailing address
1405 CHANDELL ST, KEYSER, KEYSER, WV 26726-2012
(304) 788-5961
(304) 788-5961
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
WV718-OD
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0150688000
—
WV
01
—
257851
MAMSI HEALTH INSURANCE
WV
01
—
550607791
TAX ID #
WV
Enumeration date
07/01/2005
Last updated
08/07/2008
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