Provider Demographics
NPI:1427130749
Name:MANGHAM, KIM P (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:P
Last Name:MANGHAM
Suffix:
Gender:F
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1601 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3703
Practice Address - Country:US
Practice Address - Phone:817-431-1450
Practice Address - Fax:817-431-0424
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2240192OtherFIRSTHEALTH PIN
TX00U87ZOtherBCBSTX GRP PIN
TX140442855Medicaid
TX148810803Medicaid
TX7108358OtherAETN APIN
TXMANK586404OtherCCHIP PIN
TX140442852Medicaid
TX2250136OtherUHC PIN
1750369203OtherGRP NPI NUMBER
TX8F0035OtherBCBSTX IND PIN
TX2820757OtherCIGNA PIN
TX140442855Medicaid
TX140442852Medicaid
TX00U87ZMedicare PIN