Provider Demographics
NPI:1710382817
Name:BAGWELL, DANIEL P (LMT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 STAFFORD LANE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909
Mailing Address - Country:US
Mailing Address - Phone:678-787-1886
Mailing Address - Fax:719-531-0880
Practice Address - Street 1:2620 TENDERFOOT HILL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8353
Practice Address - Country:US
Practice Address - Phone:719-527-6747
Practice Address - Fax:719-531-0880
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0016705174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist