Provider Demographics
NPI:1366484347
Name:BAGA, MELECITO E (MD)
Entity Type:Individual
Prefix:
First Name:MELECITO
Middle Name:E
Last Name:BAGA
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:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284-1508
Mailing Address - Country:US
Mailing Address - Phone:941-488-7781
Mailing Address - Fax:941-484-9234
Practice Address - Street 1:512 NOKOMIS AVE S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2817
Practice Address - Country:US
Practice Address - Phone:941-488-7781
Practice Address - Fax:941-484-9235
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00323692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038532800Medicaid
FL58290VMedicare PIN
FL038532800Medicaid