Provider Demographics
NPI:1639193311
Name:MANGLE, GEORGE MARK (DO, DPM)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MARK
Last Name:MANGLE
Suffix:
Gender:M
Credentials:DO, DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38075-4819
Mailing Address - Country:US
Mailing Address - Phone:731-254-9001
Mailing Address - Fax:731-254-9955
Practice Address - Street 1:217 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38075-4819
Practice Address - Country:US
Practice Address - Phone:731-254-9001
Practice Address - Fax:731-254-9955
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20881207R00000X
TNDO0000001690207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370122Medicare PIN
TN3000671Medicare PIN