Provider Demographics
NPI:1265410229
Name:MANGE, MONA S (MD)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:S
Last Name:MANGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:J
Other - Last Name:STEPHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3931 E 98TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-5202
Mailing Address - Country:US
Mailing Address - Phone:918-299-2389
Mailing Address - Fax:
Practice Address - Street 1:3931 E 98TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-5202
Practice Address - Country:US
Practice Address - Phone:918-299-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12981208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE58191Medicare UPIN