Provider Demographics
NPI:1396713509
Name:VAJGRT, MARY E (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:VAJGRT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7901 ANGLING RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0714
Mailing Address - Country:US
Mailing Address - Phone:269-324-8600
Mailing Address - Fax:
Practice Address - Street 1:6210 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-286-7030
Practice Address - Fax:269-286-7031
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084432207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4761693Medicaid
H80083Medicare UPIN
MIOC96076021Medicare PIN