Provider Demographics
NPI:1942279195
Name:HAGERTY, MARY M (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:HAGERTY
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 1:420 W JUBAL EARLY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6435
Mailing Address - Country:US
Mailing Address - Phone:540-667-6232
Mailing Address - Fax:540-667-6036
Practice Address - Street 1:420 W JUBAL EARLY DR STE 104
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6435
Practice Address - Country:US
Practice Address - Phone:540-667-6232
Practice Address - Fax:540-667-6036
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048922207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006085806Medicaid
VA660000002Medicare ID - Type Unspecified
VA006085806Medicaid