Provider Demographics
NPI:1518140490
Name:DAVID L. BAGNALL MD PC
Entity Type:Organization
Organization Name:DAVID L. BAGNALL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAGNALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-250-6454
Mailing Address - Street 1:3980 SHERIDAN DR
Mailing Address - Street 2:BUILDING A SUITE 102
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1727
Mailing Address - Country:US
Mailing Address - Phone:716-250-6545
Mailing Address - Fax:716-250-6566
Practice Address - Street 1:3980 SHERIDAN DR
Practice Address - Street 2:BUILDING A SUITE 102
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1727
Practice Address - Country:US
Practice Address - Phone:716-250-6545
Practice Address - Fax:716-250-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1993971174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1276Medicare PIN
NYDD1819Medicare PIN
NYDD1820Medicare PIN
NYJ400004452Medicare PIN
NYJ400003089Medicare PIN