Provider Demographics
NPI:1578725461
Name:BAGALLON, MARIO (RADIOLOGY TECH)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:BAGALLON
Suffix:
Gender:M
Credentials:RADIOLOGY TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:659 S CENTRAL VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-2790
Mailing Address - Country:US
Mailing Address - Phone:661-459-1913
Mailing Address - Fax:661-459-1974
Practice Address - Street 1:655 S CENTRAL VALLEY HWY
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-2790
Practice Address - Country:US
Practice Address - Phone:661-746-9194
Practice Address - Fax:661-746-9197
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHP00089002247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist