Basic Information
| Provider Information | |||||||||
| NPI: | 1699795377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGNUSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406845979 | ||||||||
| FaxNumber: | 4406845952 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447874 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 35-074721 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2070271 | 05 | OH | MEDICAID |