Provider Demographics
NPI:1821073230
Name:MAGONE, JERRY B (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:MAGONE
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 1:275 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3807
Mailing Address - Country:US
Mailing Address - Phone:513-424-7711
Mailing Address - Fax:513-424-3599
Practice Address - Street 1:275 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3807
Practice Address - Country:US
Practice Address - Phone:513-424-7711
Practice Address - Fax:513-424-3599
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.050466207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0661387Medicaid
OHE51835Medicare UPIN
OH0661387Medicaid