Provider Demographics
NPI:1619978939
Name:MANGUM, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:MANGUM
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 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:
Practice Address - Street 1:555 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4104
Practice Address - Country:US
Practice Address - Phone:919-774-6518
Practice Address - Fax:919-774-1831
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC53847OtherBCBS
NC8953847Medicaid
NCFH1100100OtherFIRSTCAROLINACARE
NC0138728OtherUNITED HEALTH CARE
NC27463OtherMEDCOST
P00869137OtherPALMETTO GBA - R/R MEDICARE
P00869137OtherPALMETTO GBA - R/R MEDICARE
NC8953847Medicaid
C85295Medicare UPIN