Provider Demographics
NPI:1003115536
Name:KAMANGA-SOLLO, GLADYS GRACE TIWONGE (MD)
Entity Type:Individual
Prefix:MRS
First Name:GLADYS GRACE
Middle Name:TIWONGE
Last Name:KAMANGA-SOLLO
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1723 BROADWAY ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4566
Mailing Address - Country:US
Mailing Address - Phone:573-332-7746
Mailing Address - Fax:573-339-9709
Practice Address - Street 1:1723 BROADWAY ST
Practice Address - Street 2:SUITE 410
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4566
Practice Address - Country:US
Practice Address - Phone:573-332-7746
Practice Address - Fax:573-339-9709
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2015011346208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015011346OtherMO STATE LICENSE