Provider Demographics
NPI:1104842061
Name:BAGAE, SOLOMON DAFFO (MD)
Entity Type:Individual
Prefix:
First Name:SOLOMON
Middle Name:DAFFO
Last Name:BAGAE
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 1:416 COLEGATE DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-9549
Mailing Address - Country:US
Mailing Address - Phone:740-568-4814
Mailing Address - Fax:740-374-3165
Practice Address - Street 1:400 MATTHEW ST STE 302
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-568-5207
Practice Address - Fax:740-568-5297
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.128475207RC0000X
NY001293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02116681Medicaid
NY02116681Medicaid
OHP01749424OtherRAILROAD MEDICARE - MHCPI
NYH29681Medicare UPIN
NY02116681Medicaid
OHH471491Medicare PIN