Provider Demographics
NPI:1194765263
Name:BAGWELL, SHANNON (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BAGWELL
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 725
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77383-0725
Mailing Address - Country:US
Mailing Address - Phone:812-360-5632
Mailing Address - Fax:281-236-0563
Practice Address - Street 1:10133 INTERSTATE 10 E
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521
Practice Address - Country:US
Practice Address - Phone:281-576-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061044A146D00000X
NV17878207P00000X
TXM5621207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AK763OtherBCBSTX
TX1194765263OtherTRICARE SOUTH
TX189042802Medicaid
TX189042801Medicaid
TXP00450562Medicare PIN
TX1194765263OtherTRICARE SOUTH
TX189042802Medicaid