Provider Demographics
NPI:1598097644
Name:MAGRE, LODEWIJK ANTON (MD)
Entity Type:Individual
Prefix:DR
First Name:LODEWIJK
Middle Name:ANTON
Last Name:MAGRE
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 1:228 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1420
Mailing Address - Country:US
Mailing Address - Phone:607-257-7825
Mailing Address - Fax:
Practice Address - Street 1:228 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1420
Practice Address - Country:US
Practice Address - Phone:607-257-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096177207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BM9496286OtherDEA