Provider Demographics
NPI:1568496115
Name:BAGLEY, CHARLES H (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:BAGLEY
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 1:21814 NORTHERN BLVD
Mailing Address - Street 2:101
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3581
Mailing Address - Country:US
Mailing Address - Phone:718-229-4868
Mailing Address - Fax:
Practice Address - Street 1:21814 NORTHERN BLVD
Practice Address - Street 2:101
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3581
Practice Address - Country:US
Practice Address - Phone:718-229-4868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1320242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY132024OtherNYS LICENSE
NY01015892Medicaid
NY03F072Medicare PIN
NY132024OtherNYS LICENSE