Provider Demographics
NPI:1609140847
Name:MANGUM, KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MANGUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:6095 S FASHION BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7393
Mailing Address - Country:US
Mailing Address - Phone:801-758-8735
Mailing Address - Fax:801-769-2092
Practice Address - Street 1:6095 S FASHION BLVD STE 220
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7393
Practice Address - Country:US
Practice Address - Phone:801-758-8735
Practice Address - Fax:801-769-2092
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT8164477-1204207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine