Healthcare Provider Details

I. General information

NPI: 1265450936
Provider Name (Legal Business Name): JAN MCGONAGLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 ELM ST
MANCHESTER NH
03101-1308
US

IV. Provider business mailing address

145 HOLLIS ST
MANCHESTER NH
03101-1235
US

V. Phone/Fax

Practice location:
  • Phone: 603-860-3832
  • Fax: 833-448-0645
Mailing address:
  • Phone: 603-860-3832
  • Fax: 833-448-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9425
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number9425
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420010669
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: