Provider Demographics
NPI:1205891744
Name:BACALA, AGNES C (MD)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:C
Last Name:BACALA
Suffix:
Gender:F
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:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0760
Mailing Address - Country:US
Mailing Address - Phone:812-254-2760
Mailing Address - Fax:812-254-8636
Practice Address - Street 1:12546 E US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-5220
Practice Address - Country:US
Practice Address - Phone:812-295-5095
Practice Address - Fax:812-295-9403
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32413207Q00000X
IN01043434A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00711471OtherRAILROAD MEDICARE - KY
INP00298628OtherRAILROAD MEDICARE
IN200072110Medicaid
KY64130602Medicaid
IN196290NNMedicare PIN
KYP00711471OtherRAILROAD MEDICARE - KY
KY64130602Medicaid