Provider Demographics
NPI:1437115458
Name:DAGEFORDE, JAMES RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:DAGEFORDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 GLENSIDE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-288-0399
Mailing Address - Fax:804-285-0088
Practice Address - Street 1:2200 PUMP RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-3539
Practice Address - Country:US
Practice Address - Phone:804-741-7141
Practice Address - Fax:804-741-6082
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101033721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080182284OtherRAILROAD MEDICARE
VA141477OtherANTHEM
VA005636337Medicaid
VA1437115458Medicaid
P00768408Medicare PIN
VA080182284OtherRAILROAD MEDICARE
VA141477OtherANTHEM