Healthcare Provider Details

I. General information

NPI: 1770689747
Provider Name (Legal Business Name): JOHN J MAGNUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 VILLAGE DR
SPARTA MO
65753-8104
US

IV. Provider business mailing address

155 VILLAGE DR
SPARTA MO
65753-8104
US

V. Phone/Fax

Practice location:
  • Phone: 417-634-4203
  • Fax: 417-634-4505
Mailing address:
  • Phone: 417-634-4203
  • Fax: 417-634-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2002019251
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: