Provider Demographics
NPI:1710055322
Name:MANGUM, DANIEL KEITH (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:KEITH
Last Name:MANGUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 SW HALL BLVD
Mailing Address - Street 2:#200
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-293-1515
Mailing Address - Fax:503-595-3905
Practice Address - Street 1:9900 SW HALL BLVD
Practice Address - Street 2:#200
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-293-1515
Practice Address - Fax:503-595-3905
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15821207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000625Medicaid
OR000625Medicaid
E70645Medicare UPIN