Provider Demographics
NPI:1902833627
Name:DAGEFORDE, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:DAGEFORDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:FINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CREDNTLG COORDINATOR
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:3901 DUTCHMANS LN STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4726
Practice Address - Country:US
Practice Address - Phone:502-896-2120
Practice Address - Fax:502-896-2110
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20071207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50031154OtherPASSPORT & PASSPORT ADVTG - NCVA
KYP00889587OtherMEDICARE RR - NCVA
KY1056110OtherPASSPORT PIN
KY000000693027OtherANTHEM - NCVA
KY64200710Medicaid
IN100388760FMedicaid
KY060018530OtherRAILROAD MEDICARE PIN
KY000000044911OtherANTHEM PIN
KY000057080COtherHUMANA - NCVA
KY0203578000OtherPASSPORT ADVANAGE PIN
IN100388760AMedicaid
KY0259806Medicare PIN
KYP400031668Medicare PIN
IN100388760FMedicaid
KY1271809Medicare PIN
KY1056110OtherPASSPORT PIN
KY0203578000OtherPASSPORT ADVANAGE PIN
KY060049855Medicare PIN
KY060018530OtherRAILROAD MEDICARE PIN
KY000057080COtherHUMANA - NCVA