Provider Demographics
NPI:1366417479
Name:BAGWELL, CHARLES A (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1100 WARD STREET EXT W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-1902
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:100 DOCTORS DR STE C
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2211
Practice Address - Country:US
Practice Address - Phone:912-384-5832
Practice Address - Fax:912-383-8279
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA050494208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1105865OtherCLIA ID - 17 JOHNSON ST
GA341153OtherWELLCARE OF GEORGIA
GA000919729BMedicaid
GA000919729CMedicaid
GA050494OtherGA LICENSE
GA050494OtherMEDICAL LICENSE
GA11D0265294OtherCLIA ID - 1309 OCILLA RD STE A
GAPTAN P00473716OtherRAILROAD MEDICARE - PALMETTO GBA
GA129049OtherPEACHSTATE
GAGROUP #DH1281OtherRAILROAD MEDICARE - PALMETTO GBA
GAGROUP #DH1281OtherRAILROAD MEDICARE - PALMETTO GBA
GAGRP7930Medicare PIN
GA11D0265294OtherCLIA ID - 1309 OCILLA RD STE A
GA11D1105865OtherCLIA ID - 17 JOHNSON ST