Provider Demographics
NPI:1013025295
Name:BAGDASARIAN, RAINER WOLF (MD)
Entity Type:Individual
Prefix:
First Name:RAINER
Middle Name:WOLF
Last Name:BAGDASARIAN
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 1:25 NEWELL RD
Mailing Address - Street 2:SUITE D28
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010
Mailing Address - Country:US
Mailing Address - Phone:860-583-2003
Mailing Address - Fax:860-582-6255
Practice Address - Street 1:25 NEWELL RD
Practice Address - Street 2:SUITE D28
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-583-2003
Practice Address - Fax:860-582-6255
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038365208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001383653Medicaid
CT020001452Medicare ID - Type Unspecified
CT001383653Medicaid