Provider Demographics
NPI:1689804254
Name:BAGLEY, RONALD DEMETRIC (IDMT)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DEMETRIC
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PSC 3 BOX 3231
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96266-0032
Mailing Address - Country:US
Mailing Address - Phone:0108-680-9949
Mailing Address - Fax:312-784-3468
Practice Address - Street 1:51 MDOS/ SGOE
Practice Address - Street 2:BLDG. 777 UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:312-784-2500
Practice Address - Fax:312-784-3468
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians