Provider Demographics
NPI:1437278397
Name:BAGGETT, LARRY
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:BAGGETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3794 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-6649
Mailing Address - Country:US
Mailing Address - Phone:901-323-7970
Mailing Address - Fax:901-323-0061
Practice Address - Street 1:3794 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-6649
Practice Address - Country:US
Practice Address - Phone:901-323-7970
Practice Address - Fax:901-323-0061
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM285213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351088Medicaid
TN3351088Medicare ID - Type Unspecified
TN3351088Medicaid