Provider Demographics
NPI:1770689747
Name:MAGNUSON, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:MAGNUSON
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 1:155 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MO
Mailing Address - Zip Code:65753-8104
Mailing Address - Country:US
Mailing Address - Phone:417-634-4203
Mailing Address - Fax:417-634-4505
Practice Address - Street 1:155 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MO
Practice Address - Zip Code:65753-8104
Practice Address - Country:US
Practice Address - Phone:417-634-4203
Practice Address - Fax:417-634-4505
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002019251208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205921703Medicaid
P00361139OtherRR MEDICARE
MO1770689747Medicaid
MOH74858Medicare UPIN
MO501150021Medicare PIN
MO1770689747Medicaid