Provider Demographics
NPI:1164685004
Name:MANGANA, SOPHY H (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHY
Middle Name:H
Last Name:MANGANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SOPHY
Other - Middle Name:Y
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 15158
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-5158
Mailing Address - Country:US
Mailing Address - Phone:601-288-1700
Mailing Address - Fax:601-288-1715
Practice Address - Street 1:301 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7233
Practice Address - Country:US
Practice Address - Phone:601-288-1700
Practice Address - Fax:601-288-1715
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250539302085R0001X
MS221472085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01454791OtherRAILROAD MEDICARE PTAN
AL141656Medicaid
MS02486090Medicaid
AL141656Medicaid
MS256370YJ5DMedicare PIN