Provider Demographics
NPI:1982693826
Name:MANGRUM, CHARLITA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLITA
Middle Name:
Last Name:MANGRUM
Suffix:
Gender:F
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:1021 W HAMLET AVE
Practice Address - Street 2:SUITE#5
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-4523
Practice Address - Country:US
Practice Address - Phone:910-582-5166
Practice Address - Fax:910-582-5168
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016EOOtherCAROLINA ACCESS
NC89138KXMedicaid
NC138KXOtherBCBS INDIV
NCP00687321OtherRR MEDICARE
NCP00267476OtherRAILROAD MEDICARE
SCN01535Medicaid
NC2036311BMedicare PIN
SCN01535Medicaid