Provider Demographics
NPI:1689157471
Name:BANAGA, TAGELDIN
Entity Type:Individual
Prefix:
First Name:TAGELDIN
Middle Name:
Last Name:BANAGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 E MAIN ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-1400
Mailing Address - Country:US
Mailing Address - Phone:203-543-3819
Mailing Address - Fax:
Practice Address - Street 1:1333 E MAIN ST APT 5
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1400
Practice Address - Country:US
Practice Address - Phone:203-543-3819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017671860172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver