Provider Demographics
NPI:1790910412
Name:MANGONA, VICTOR SUVA-VIOLA (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:SUVA-VIOLA
Last Name:MANGONA
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:1501 W ROYAL LN
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3213
Practice Address - Country:US
Practice Address - Phone:469-513-5500
Practice Address - Fax:469-420-9600
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094323207R00000X
TXQ50282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348568201Medicaid
TX348568203Medicaid
AR240726001Medicaid
KS201312910AMedicaid
TX348568202Medicaid
TXP01667436OtherRAILROAD