1619978939 NPI number — JOHN R MANGUM MD

Table of content: JOHN R MANGUM MD (NPI 1619978939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619978939 NPI number — JOHN R MANGUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGUM
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619978939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 PAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28374-8798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-295-5511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 CARTHAGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27330-4104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-774-6518
Provider Business Practice Location Address Fax Number:
919-774-1831
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  26630 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 53847 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8953847 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: FH1100100 . This is a "FIRSTCAROLINACARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0138728 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 27463 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00869137 . This is a "PALMETTO GBA - R/R MEDICARE" identifier . This identifiers is of the category "OTHER".




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