Provider Demographics
NPI:1225159296
Name:BAGLEY, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BAGLEY
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 1:201 S ROSE ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-2451
Mailing Address - Country:US
Mailing Address - Phone:870-917-2171
Mailing Address - Fax:870-917-2161
Practice Address - Street 1:201 S ROSE ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-2451
Practice Address - Country:US
Practice Address - Phone:870-917-2171
Practice Address - Fax:870-917-2161
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-54382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191187001Medicaid