Basic Information
| Provider Information | |||||||||
| NPI: | 1790910412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGONA | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | SUVA-VIOLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W ROYAL LN | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750633213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4695135500 | ||||||||
| FaxNumber: | 4694209600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301094323 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0001X | Q5028 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 348568201 | 05 | TX | MEDICAID | 348568203 | 05 | TX | MEDICAID | 240726001 | 05 | AR | MEDICAID | 201312910A | 05 | KS | MEDICAID | 348568202 | 05 | TX | MEDICAID | P01667436 | 01 | TX | RAILROAD | OTHER |