Provider Demographics
NPI:1568687978
Name:BAGG, JENNIFER GAIL (MD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GAIL
Last Name:BAGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804
Mailing Address - Country:US
Mailing Address - Phone:914-576-2010
Mailing Address - Fax:914-576-2529
Practice Address - Street 1:1255 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804
Practice Address - Country:US
Practice Address - Phone:914-576-2010
Practice Address - Fax:914-576-2529
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01735473Medicaid
E87574Medicare UPIN
NY01735473Medicaid