Provider Demographics
NPI:1568474567
Name:SEO, MANGIL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANGIL
Middle Name:
Last Name:SEO
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 1:4505 SW 9TH ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-3939
Mailing Address - Country:US
Mailing Address - Phone:515-287-7111
Mailing Address - Fax:515-287-7114
Practice Address - Street 1:4505 SW 9TH ST
Practice Address - Street 2:SUITE #1
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-3939
Practice Address - Country:US
Practice Address - Phone:515-287-7111
Practice Address - Fax:515-287-7114
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19652207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3080598Medicaid
IA15968Medicare ID - Type Unspecified
IA3080598Medicaid