Provider Demographics
NPI:1497890867
Name:MAHONEY, MICHAEL W (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:MAHONEY
Suffix:
Gender:M
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:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-0019
Mailing Address - Country:US
Mailing Address - Phone:573-486-1193
Mailing Address - Fax:573-486-0910
Practice Address - Street 1:134 W 6TH ST
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1018
Practice Address - Country:US
Practice Address - Phone:573-486-5711
Practice Address - Fax:573-486-3827
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240883801Medicaid