Provider Demographics
NPI:1649595216
Name:BAGLEY, ADAM WALKER (MD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:WALKER
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1660 PRUDENTIAL DR
Practice Address - Street 2:SUITE 310
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8197
Practice Address - Country:US
Practice Address - Phone:904-396-8656
Practice Address - Fax:904-396-5931
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123101207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01510416OtherRR MEDICARE
FL014634200Medicaid
FL014634200Medicaid