Provider Demographics
NPI:1346265162
Name:MANGWIRO, AUDREY N (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:N
Last Name:MANGWIRO
Suffix:
Gender:F
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:PO BOX 2701
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2701
Mailing Address - Country:US
Mailing Address - Phone:903-315-1488
Mailing Address - Fax:903-315-1656
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-1488
Practice Address - Fax:903-315-1656
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4318207P00000X, 207R00000X
LA15590R207R00000X
MN74111208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1476510Medicaid
LAI28709Medicare UPIN
LA1476510Medicaid