Provider Demographics
NPI:1023010964
Name:HOGAN, MARY P (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:HOGAN
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 1:1005 DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-776-8428
Mailing Address - Fax:928-776-8057
Practice Address - Street 1:1005 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1601
Practice Address - Country:US
Practice Address - Phone:928-776-8428
Practice Address - Fax:928-776-8057
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53387207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD76498Medicare UPIN
MD354P712GMedicare PIN
MD310411700Medicaid