Provider Demographics
NPI:1417996208
Name:BARDGETTE, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:BARDGETTE
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 1:2329 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3003
Mailing Address - Country:US
Mailing Address - Phone:254-752-5503
Mailing Address - Fax:254-752-4844
Practice Address - Street 1:2329 N 39TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3003
Practice Address - Country:US
Practice Address - Phone:254-752-5503
Practice Address - Fax:254-752-4844
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2458207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119142101Medicaid
C13151Medicare UPIN
883327Medicare ID - Type Unspecified