Provider Demographics
NPI:1568424869
Name:BAGWELL, JOHNNY WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:WAYNE
Last Name:BAGWELL
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 1:801 POOLE DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-5207
Mailing Address - Country:US
Mailing Address - Phone:919-779-1440
Mailing Address - Fax:919-662-0613
Practice Address - Street 1:801 POOLE DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-5207
Practice Address - Country:US
Practice Address - Phone:919-779-1440
Practice Address - Fax:919-662-0613
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912480Medicaid
204577CMedicare ID - Type Unspecified
C82665Medicare UPIN