Healthcare Provider Details

I. General information

NPI: 1467472381
Provider Name (Legal Business Name): MARY ANN MAGOUN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 E. SECOND STREET SUITE 5
POMONA CA
91776-2007
US

IV. Provider business mailing address

795 E. SECOND STREET SUITE 5
POMONA CA
91776-2007
US

V. Phone/Fax

Practice location:
  • Phone: 909-865-2565
  • Fax: 909-865-2955
Mailing address:
  • Phone: 909-865-2565
  • Fax: 909-865-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A8657
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A8657
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: