Provider Demographics
NPI:1013993096
Name:MAGNON, ROBERT JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:MAGNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE 525
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5609
Mailing Address - Country:US
Mailing Address - Phone:210-225-2769
Mailing Address - Fax:210-225-7576
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:SUITE 525
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5609
Practice Address - Country:US
Practice Address - Phone:210-225-2769
Practice Address - Fax:210-225-7576
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE6134207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115647301Medicaid
TX115647302Medicaid
TX115647301Medicaid
TX00NT99Medicare PIN
TXB24567Medicare UPIN