Provider Demographics
NPI:1972565224
Name:MANGHAM, CHARLES A JR (MD, MS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:MANGHAM
Suffix:JR
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY
Practice Address - Street 2:STE 830
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4396
Practice Address - Country:US
Practice Address - Phone:206-328-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013302207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1130606Medicaid
WAMD00013302OtherSTATE MEDICAL LICENSE
WAMD00013302OtherSTATE MEDICAL LICENSE
WAA05087Medicare UPIN
AM9216993OtherDRUG ENFORCEMENT AGENCY