Provider Demographics
NPI:1972558781
Name:MCGONAGLE, MARY KATHERINE (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:MCGONAGLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:800-257-0117
Mailing Address - Fax:610-550-3079
Practice Address - Street 1:3805 W CHESTER PIKE
Practice Address - Street 2:BLDG D, SUITE 120
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2329
Practice Address - Country:US
Practice Address - Phone:800-257-0117
Practice Address - Fax:610-550-3079
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013614207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I52853Medicare UPIN
PA101242KS5Medicare ID - Type Unspecified