Provider Demographics
NPI:1699986752
Name:PERRY, GLORIA MANGUM (MD)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:MANGUM
Last Name:PERRY
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 1:107 BRIDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8302
Mailing Address - Country:US
Mailing Address - Phone:601-992-7168
Mailing Address - Fax:601-992-2352
Practice Address - Street 1:107 BRIDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8302
Practice Address - Country:US
Practice Address - Phone:601-359-5155
Practice Address - Fax:601-359-5725
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017860Medicaid
MS00017860Medicaid