Provider Demographics
NPI:1104851880
Name:MANGE, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MANGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 GRIFFITH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-9304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 GRIFFITH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-9304
Practice Address - Country:US
Practice Address - Phone:704-801-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8953838Medicaid
NC53838OtherBCBS
NC370005153OtherMEDICARE RAILROAD
NC212456AMedicare PIN
NC370005153OtherMEDICARE RAILROAD
NC8953838Medicaid