Healthcare Provider Details

I. General information

NPI: 1669291845
Provider Name (Legal Business Name): MAGOON PRIVATE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6104 BROADWAY STE C-1
ALAMO HEIGHTS TX
78209-4553
US

IV. Provider business mailing address

8107 PRINCESS CT
SAN ANTONIO TX
78209-2253
US

V. Phone/Fax

Practice location:
  • Phone: 210-756-0800
  • Fax: 210-756-0900
Mailing address:
  • Phone: 210-862-6064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL MAGOON
Title or Position: OWNER
Credential: MD
Phone: 210-862-6064