Provider Demographics
NPI:1871698308
Name:MCGONAGLE, MARTIN EUGENE (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:EUGENE
Last Name:MCGONAGLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33648
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162
Mailing Address - Country:US
Mailing Address - Phone:817-579-2660
Mailing Address - Fax:817-579-2663
Practice Address - Street 1:763 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3148
Practice Address - Country:US
Practice Address - Phone:254-965-7870
Practice Address - Fax:254-965-5373
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6563207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126628001Medicaid
TX00L43YMedicare ID - Type UnspecifiedBROWNWOOD OFC.
TX126628001Medicaid
TX00K94WMedicare ID - Type UnspecifiedGRANBURY OFC.
TX00FH02Medicare ID - Type UnspecifiedSTEPHENVILLE OFC