Provider Demographics
NPI:1457325607
Name:MCMAHON, BRIAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:MCMAHON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 RICE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2509
Mailing Address - Country:US
Mailing Address - Phone:718-390-0400
Mailing Address - Fax:718-390-0566
Practice Address - Street 1:125 SLOSSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2517
Practice Address - Country:US
Practice Address - Phone:719-390-0400
Practice Address - Fax:718-390-0566
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168902208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA65191Medicare UPIN