Healthcare Provider Details

I. General information

NPI: 1609140847
Provider Name (Legal Business Name): KEVIN MANGUM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 S FASHION BLVD STE 220
MURRAY UT
84107-7393
US

IV. Provider business mailing address

6095 S FASHION BLVD STE 220
MURRAY UT
84107-7393
US

V. Phone/Fax

Practice location:
  • Phone: 801-758-8735
  • Fax: 801-769-2092
Mailing address:
  • Phone: 801-758-8735
  • Fax: 801-769-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8164477-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number8164477-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: