Provider Demographics
NPI:1245245760
Name:BAGBY, SUSAN POUND (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:POUND
Last Name:BAGBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 SW US VETERANS HOSPITAL RD
Mailing Address - Street 2:MAIL CODE PP262
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2940
Mailing Address - Country:US
Mailing Address - Phone:503-494-8490
Mailing Address - Fax:503-494-5330
Practice Address - Street 1:3314 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:MAIL CODE PP262
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2940
Practice Address - Country:US
Practice Address - Phone:503-494-8490
Practice Address - Fax:503-494-5330
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09557207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR042028Medicaid
C92127Medicare UPIN