MEDICARE: MANGO MEDICAL DPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1548029580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANGO MEDICAL DPC

Provider Business Mailing Address
First Line	:	23 S MALLORY ST STE B
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23663-1707
Country	:	US
Telephone Number	:	757-210-5959
Fax Number	:	800-313-5613

Provider Business Practice Location Address
First Line	:	23 S MALLORY ST STE C
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23663-1707
Country	:	US
Telephone Number	:	757-210-5959
Fax Number	:	800-313-5613

Authorized Official
Title or Position	:	MD/CEO
Name	:	NZINGA TEULE-HEKIMA
Credential	:	MD
Telephone Number	:	757-210-5959

Provider Enumeration Date	:	03/13/2024
Last Update Date	:	12/04/2024

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