Provider Demographics
NPI:1265450936
Name:MCGONAGLE, JAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:MCGONAGLE
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 1:99 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3210
Mailing Address - Country:US
Mailing Address - Phone:603-358-3927
Mailing Address - Fax:
Practice Address - Street 1:ONE VERNEY DRIVE
Practice Address - Street 2:CMRC
Practice Address - City:GREENFIELD
Practice Address - State:NH
Practice Address - Zip Code:03431-1719
Practice Address - Country:US
Practice Address - Phone:603-547-3311
Practice Address - Fax:603-547-3232
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9425208000000X, 2080P0008X
VT0420010669208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30008409Medicaid
VTORE3780Medicaid
G09289Medicare UPIN
NHRE3780Medicare ID - Type Unspecified