Provider Demographics
NPI:1164995395
Name:BAGG, DOUGLAS STEWART III
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:STEWART
Last Name:BAGG
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 BAYMEADOWS RD APT 210
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7100
Mailing Address - Country:US
Mailing Address - Phone:386-984-8790
Mailing Address - Fax:
Practice Address - Street 1:10100 BAYMEADOWS RD APT 210
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7100
Practice Address - Country:US
Practice Address - Phone:386-984-8790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer