Provider Demographics
NPI:1588621353
Name:YUENGERT, MARY AGNES (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AGNES
Last Name:YUENGERT
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-822-4355
Mailing Address - Fax:
Practice Address - Street 1:611 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4415
Practice Address - Country:US
Practice Address - Phone:757-283-8300
Practice Address - Fax:757-448-1037
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVC244AMedicare PIN
2671966OtherCIGNA
5785278OtherAETNA
1383297OtherFIRST HEALTH
F93729Medicare UPIN
010720275OtherVHN
VA080008250Medicare PIN
839478OtherMAMSI
9261845OtherPHCS
VA5609950Medicaid
VA17652OtherOPTIMA
VAMC12197 - C03895Medicare PIN
010720275OtherTRICARE
010720275OtherVICARE
VA236108OtherANTHEM BC/BS