Provider Demographics
NPI:1174603104
Name:HOGAN, MARY BETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:HOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 PINTO LN FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4195
Mailing Address - Country:US
Mailing Address - Phone:702-992-6868
Mailing Address - Fax:702-992-6860
Practice Address - Street 1:1600 MEDICAL CENTER DR STE 3500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3655
Practice Address - Country:US
Practice Address - Phone:304-691-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV122652080P0201X
WV182822080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0109785000Medicaid
NVV106921Medicare PIN
F79264Medicare UPIN