Provider Demographics
NPI:1598719411
Name:BAGNOLI, NICHOLAS G (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:G
Last Name:BAGNOLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:G
Other - Last Name:BAGNOLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:3869 WINDERLAKES DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-2625
Mailing Address - Country:US
Mailing Address - Phone:407-210-4251
Mailing Address - Fax:407-648-0968
Practice Address - Street 1:1220 SLIGH BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1108
Practice Address - Country:US
Practice Address - Phone:407-210-4251
Practice Address - Fax:407-648-0968
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVOS7417208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57552OtherBCBS
FL7848047011OtherCIGNA
FL3123096OtherAETNA
FL252446500Medicaid
FL57552AMedicare PIN
FL3123096OtherAETNA
FLP00016148Medicare PIN