Provider Demographics
NPI:1457327272
Name:MANGUN, JENNIE CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:CRAIG
Last Name:MANGUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:CRAIG
Other - Last Name:BARNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-636-1919
Mailing Address - Fax:252-636-2656
Practice Address - Street 1:2636 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4238
Practice Address - Country:US
Practice Address - Phone:252-636-1919
Practice Address - Fax:252-636-2656
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC009000700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141Y6OtherBCBSNC
NC5903648Medicaid
NC2051079BMedicare PIN
NC5903648Medicaid