Provider Demographics
NPI:1962398263
Name:MANGAN, ENRIQUE DANIEL
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:DANIEL
Last Name:MANGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 SOUTHAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-1714
Mailing Address - Country:US
Mailing Address - Phone:432-556-6430
Mailing Address - Fax:
Practice Address - Street 1:3500 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2644
Practice Address - Country:US
Practice Address - Phone:817-735-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program