Provider Demographics
NPI:1083864649
Name:IDUMANGE, IDUMANGE T (PT)
Entity type:Individual
Prefix:
First Name:IDUMANGE
Middle Name:T
Last Name:IDUMANGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:008-824-4094
Mailing Address - Fax:
Practice Address - Street 1:505 W PERSHING BLVD STE D
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2157
Practice Address - Country:US
Practice Address - Phone:501-812-4970
Practice Address - Fax:501-812-4972
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1965225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist