Provider Demographics
NPI:1245403666
Name:OLIVER DALE BAGLEY D.P.M., INC.
Entity Type:Organization
Organization Name:OLIVER DALE BAGLEY D.P.M., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:530-244-0674
Mailing Address - Street 1:1310 CONTINENTAL ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0839
Mailing Address - Country:US
Mailing Address - Phone:530-244-0674
Mailing Address - Fax:530-244-1033
Practice Address - Street 1:1310 CONTINENTAL ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0839
Practice Address - Country:US
Practice Address - Phone:530-244-0674
Practice Address - Fax:530-244-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1237213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4473230001Medicare NSC
CAT10848Medicare UPIN
CA000E12370Medicare PIN