Provider Demographics
NPI:1982666210
Name:MANGUM, CHARLES E (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
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 226
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-0226
Mailing Address - Country:US
Mailing Address - Phone:972-526-0340
Mailing Address - Fax:972-996-1857
Practice Address - Street 1:7501 LAKEVIEW PKWY
Practice Address - Street 2:STE 160
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-9322
Practice Address - Country:US
Practice Address - Phone:972-526-0340
Practice Address - Fax:972-996-1857
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3349207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00295238OtherRAILROAD MEDICARE
TX8BX668OtherBLUE CROSS BLUE SHIELD
TX117454204Medicaid
TX117454205Medicaid
TX8U7632OtherBLUE CROSS BLUE SHIELD
TX8BX668OtherBLUE CROSS BLUE SHIELD
TXP00295238OtherRAILROAD MEDICARE
TX117454204Medicaid