Provider Demographics
NPI:1104873108
Name:MANGAN, MARTIN JOSEPH III (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:JOSEPH
Last Name:MANGAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 DOVE RUN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3536
Mailing Address - Country:US
Mailing Address - Phone:859-269-4668
Mailing Address - Fax:859-266-5577
Practice Address - Street 1:1055 DOVE RUN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3536
Practice Address - Country:US
Practice Address - Phone:859-269-4668
Practice Address - Fax:859-266-5577
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY32706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64327067Medicaid
KYK079510Medicare PIN
C32159Medicare UPIN