Provider Demographics
NPI:1548566904
Name:BAGENHOLM, BO (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:
Last Name:BAGENHOLM
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 1:1704 DUFFY LOOP
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-4093
Mailing Address - Country:US
Mailing Address - Phone:352-350-2530
Mailing Address - Fax:352-350-2530
Practice Address - Street 1:1704 DUFFY LOOP
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-4093
Practice Address - Country:US
Practice Address - Phone:352-350-2530
Practice Address - Fax:352-350-2530
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24950207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL50474-2Medicaid