Provider Demographics
NPI:1629132899
Name:MANG, DZUNG DUC-TIEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DZUNG
Middle Name:DUC-TIEN
Last Name:MANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRANDON-DZUNG
Other - Middle Name:DUC-TIEN
Other - Last Name:MANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6650 78TH AVENUE N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-2053
Mailing Address - Country:US
Mailing Address - Phone:727-548-7600
Mailing Address - Fax:727-548-7608
Practice Address - Street 1:6650 78TH AVENUE N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2053
Practice Address - Country:US
Practice Address - Phone:727-548-7600
Practice Address - Fax:727-548-7608
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86632208200000X
GA054429208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82248ZMedicare ID - Type UnspecifiedPLASTIC SURGERY
FLH99343Medicare UPIN