1790910412 NPI number — VICTOR SUVA-VIOLA MANGONA MD

Table of content: VICTOR SUVA-VIOLA MANGONA MD (NPI 1790910412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790910412 NPI number — VICTOR SUVA-VIOLA MANGONA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGONA
Provider First Name:
VICTOR
Provider Middle Name:
SUVA-VIOLA
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:
1790910412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75391-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-997-8000
Provider Business Mailing Address Fax Number:
972-234-2987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 W ROYAL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75063-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-513-5500
Provider Business Practice Location Address Fax Number:
469-420-9600
Provider Enumeration Date:
05/26/2009

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: 207R00000X , with the licence number:  4301094323 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: Q5028 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 348568201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348568203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240726001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201312910A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348568202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01667436 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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