Provider Demographics
NPI:1336239359
Name:MANGUM, GREGORY LEE (DPM)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:MANGUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4868 BEECHNUT ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096
Mailing Address - Country:US
Mailing Address - Phone:713-664-6677
Mailing Address - Fax:713-664-7096
Practice Address - Street 1:4868 BEECHNUT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096
Practice Address - Country:US
Practice Address - Phone:713-664-6677
Practice Address - Fax:713-664-7096
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0607213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0607OtherLISCENCE
TXJ0084884OtherDPS
TX121579003Medicaid
TX121579003Medicaid
TXJ0084884OtherDPS