Healthcare Provider Details

I. General information

NPI: 1982693826
Provider Name (Legal Business Name): CHARLITA MANGRUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W HAMLET AVE SUITE#5
HAMLET NC
28345-4523
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-582-5166
  • Fax: 910-582-5168
Mailing address:
  • Phone: 704-384-7840
  • Fax: 704-384-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200401535
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: