Provider Demographics
NPI:1508853219
Name:BAGNATO, VITO JOHN (MD)
Entity Type:Individual
Prefix:
First Name:VITO
Middle Name:JOHN
Last Name:BAGNATO
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 1:420 CHARTER BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-471-8484
Mailing Address - Fax:478-471-8487
Practice Address - Street 1:420 CHARTER BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:478-471-8484
Practice Address - Fax:478-471-8487
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45711208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00798663AMedicaid
GAB29937Medicare UPIN
GA00798663AMedicaid