Provider Demographics
NPI:1467472381
Name:MAGOUN, MARY ANN (DO)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:MAGOUN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 E. SECOND STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91776-2007
Mailing Address - Country:US
Mailing Address - Phone:909-865-2565
Mailing Address - Fax:909-865-2955
Practice Address - Street 1:795 E. SECOND STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91776-2007
Practice Address - Country:US
Practice Address - Phone:909-865-2565
Practice Address - Fax:909-865-2955
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8657204D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX86570Medicaid
CA20A8657OtherSTATE LICENSE
I24618Medicare UPIN
CA00AX86570Medicaid