Provider Demographics
NPI:1679641799
Name:MANGUM, DONALD H (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:H
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 3300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-5200
Practice Address - Fax:417-820-5220
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1P79207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE
MO202989018Medicaid
MO202989018Medicaid
MOE78364Medicare UPIN