Provider Demographics
NPI:1194780270
Name:BAGBY, RICHARD JULIAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JULIAN
Last Name:BAGBY
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 1:500 WEST MAIN STREET
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702
Mailing Address - Country:US
Mailing Address - Phone:631-517-8006
Mailing Address - Fax:631-517-8007
Practice Address - Street 1:398 EAST ALTAMONTE DRIVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:407-331-9355
Practice Address - Fax:407-331-9481
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48716Medicare ID - Type Unspecified
D55411Medicare UPIN