Provider Demographics
NPI:1295399186
Name:MANGUM, KEVIN DALE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
Last Name:MANGUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E MEDICAL CENTER DRIVE
Mailing Address - Street 2:5346 CVC
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE SPC 5856
Practice Address - Street 2:FCVC 3RD FLOOR, RECEPTION B
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5856
Practice Address - Country:US
Practice Address - Phone:734-936-5850
Practice Address - Fax:734-647-4285
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351044158390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program