Provider Demographics
NPI:1093864373
Name:MAUNGLAY, SOE TIN (MD)
Entity Type:Individual
Prefix:
First Name:SOE
Middle Name:TIN
Last Name:MAUNGLAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:51753 EL DORADO DR
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-9034
Mailing Address - Country:US
Mailing Address - Phone:760-619-2309
Mailing Address - Fax:866-428-0708
Practice Address - Street 1:4500 BROCKTON AVE STE 316
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4090
Practice Address - Country:US
Practice Address - Phone:951-394-3055
Practice Address - Fax:951-394-3077
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2020-09-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC152411207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277913700Medicaid
AL124493OtherAL MEDICAID- BREWTON
AL124237OtherAL MEDICAID- NORTH DAVIS
MI093-896OtherBLUE CROSS BLUE SHEILD
AL124241OtherAL MEDICAID- GULF BREEZE
MIP17390012OtherMEDICARE
MIP17390012OtherMEDICARE
MI1801942453Medicaid
FLAD511XMedicare PIN