Basic Information
| Provider Information | |||||||||
| NPI: | 1093864373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUNGLAY | ||||||||
| FirstName: | SOE | ||||||||
| MiddleName: | TIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51753 EL DORADO DR | ||||||||
| Address2: | |||||||||
| City: | LA QUINTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922539034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606192309 | ||||||||
| FaxNumber: | 8664280708 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 BROCKTON AVE STE 316 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513943055 | ||||||||
| FaxNumber: | 9513943077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | C152411 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 277913700 | 05 | FL | MEDICAID | 124493 | 01 | AL | AL MEDICAID- BREWTON | OTHER | 124237 | 01 | AL | AL MEDICAID- NORTH DAVIS | OTHER | 093-896 | 01 | MI | BLUE CROSS BLUE SHEILD | OTHER | 124241 | 01 | AL | AL MEDICAID- GULF BREEZE | OTHER | P17390012 | 01 | MI | MEDICARE | OTHER |