Provider Demographics
NPI:1609854249
Name:BAGNER, JEROME EDWARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:EDWARD
Last Name:BAGNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HEMPSTEAD AVE
Mailing Address - Street 2:STE 158
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4033
Mailing Address - Country:US
Mailing Address - Phone:516-764-6800
Mailing Address - Fax:516-764-7047
Practice Address - Street 1:30 HEMPSTEAD AVE
Practice Address - Street 2:STE 158
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4033
Practice Address - Country:US
Practice Address - Phone:516-764-6800
Practice Address - Fax:516-764-7047
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0022331213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00405023Medicaid
NY5925220001Medicare NSC
NY00405023Medicaid
NYP2477100Medicare PIN