Provider Demographics
NPI: | 1508030321 |
---|---|
Name: | BAGDURE, DAYANAND (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | DAYANAND |
Middle Name: | |
Last Name: | BAGDURE |
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: | 1512 W KIRBY PL |
Mailing Address - Street 2: | |
Mailing Address - City: | SHREVEPORT |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 71103-3822 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 318-626-0287 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1541 KINGS HWY |
Practice Address - Street 2: | |
Practice Address - City: | SHREVEPORT |
Practice Address - State: | LA |
Practice Address - Zip Code: | 71103-4228 |
Practice Address - Country: | US |
Practice Address - Phone: | 318-626-0000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-04-14 |
Last Update Date: | 2024-03-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | D72899 | 208000000X, 2080P0203X |
CO | 47772 | 208000000X |
LA | 328967 | 208000000X, 2080P0203X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2080P0203X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 26880024 | Medicaid | |
MD | 335209900 | Medicaid | |
CO | COA102936 | Medicare PIN |