Provider Demographics
NPI:1487129367
Name:COGOLLO MANGONES, VICENTE JOSE (MD)
Entity type:Individual
Prefix:
First Name:VICENTE
Middle Name:JOSE
Last Name:COGOLLO MANGONES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12160 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-1623
Mailing Address - Country:US
Mailing Address - Phone:305-491-6087
Mailing Address - Fax:
Practice Address - Street 1:11750 BIRD RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3530
Practice Address - Country:US
Practice Address - Phone:305-223-2000
Practice Address - Fax:305-227-5556
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME163948208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program