Provider Demographics
NPI:1457483604
Name:MANGUNO-MIRE, GINA (PHD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:MANGUNO-MIRE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 CANAL ST
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2703
Mailing Address - Country:US
Mailing Address - Phone:504-988-2201
Mailing Address - Fax:504-988-4270
Practice Address - Street 1:1440 CANAL ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2703
Practice Address - Country:US
Practice Address - Phone:504-988-2201
Practice Address - Fax:504-988-4270
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA930174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist