Provider Demographics
NPI:1023067584
Name:MANGONON, PATRICK TERRY (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:TERRY
Last Name:MANGONON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5168
Mailing Address - Country:US
Mailing Address - Phone:386-231-3600
Mailing Address - Fax:386-231-3602
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 308
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5168
Practice Address - Country:US
Practice Address - Phone:386-231-3600
Practice Address - Fax:386-231-3602
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77600208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256707500Medicaid
FL256707500Medicaid
FLH04350Medicare UPIN