Basic Information
| Provider Information | |||||||||
| NPI: | 1619978939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGUM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 PAGE RD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 CARTHAGE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746518 | ||||||||
| FaxNumber: | 9197741831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26630 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 53847 | 01 | NC | BCBS | OTHER | 8953847 | 05 | NC | MEDICAID | FH1100100 | 01 | NC | FIRSTCAROLINACARE | OTHER | 0138728 | 01 | NC | UNITED HEALTH CARE | OTHER | 27463 | 01 | NC | MEDCOST | OTHER | P00869137 | 01 | PALMETTO GBA - R/R MEDICARE | OTHER |