Provider Demographics
NPI:1336141167
Name:MAHON, ROBERT G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:MAHON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 E NORTH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-2437
Mailing Address - Country:US
Mailing Address - Phone:864-234-7815
Mailing Address - Fax:864-234-7846
Practice Address - Street 1:4200 E NORTH ST STE 5
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-234-7815
Practice Address - Fax:864-234-7846
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4693207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC046934Medicaid
SC046934Medicaid