Provider Demographics
NPI:1649212564
Name:MAGRUDER, MARY JANE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:MAGRUDER
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 1:2020 PALOMINO LN
Mailing Address - Street 2:STE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4894
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:702-384-1815
Practice Address - Street 1:2020 PALOMINO LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4894
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:702-384-1815
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV83142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200290024Medicaid
OK200471160AMedicaid
NVP01168764OtherRR MEDICARE
CA1649212564Medicaid
OK200471160AMedicaid
NV30WCCBT28Medicare PIN
NVP01168764OtherRR MEDICARE
CA1649212564Medicaid