Provider Demographics
NPI:1235173485
Name:MUGO, MARYANN N (MD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:N
Last Name:MUGO
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 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:48 HILLS CREEK RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30178-2051
Practice Address - Country:US
Practice Address - Phone:770-684-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57010207RE0101X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
204610OtherBCBS
P00371698OtherRAILROAD MEDICARE
MO200647907Medicaid
204610OtherBCBS
938144837Medicare PIN