Provider Demographics
NPI:1063664407
Name:MAGAR, MIRIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIVA
Middle Name:
Last Name:MAGAR
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 1:1717 S CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-5257
Mailing Address - Country:US
Mailing Address - Phone:260-458-2641
Mailing Address - Fax:
Practice Address - Street 1:1717 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-5257
Practice Address - Country:US
Practice Address - Phone:260-458-2641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098894208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
B56065054OtherMEDICARE PTAN