Provider Demographics
NPI:1790703486
Name:BAGLEY, MICHAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 INGRAM CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747
Mailing Address - Country:US
Mailing Address - Phone:732-583-3886
Mailing Address - Fax:
Practice Address - Street 1:122 MT BETHEL RD STE 1
Practice Address - Street 2:WARREN DERMATOLOGY ASSOC LLC
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059
Practice Address - Country:US
Practice Address - Phone:908-756-7999
Practice Address - Fax:908-756-8017
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04581000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223824190OtherGROUP TAX ID
NJ223824190OtherGROUP TAX ID
NJ157365P67Medicare ID - Type Unspecified