Provider Demographics
NPI:1366908337
Name:BAGALSO, GERARD (IDC)
Entity type:Individual
Prefix:MR
First Name:GERARD
Middle Name:
Last Name:BAGALSO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11126 ALMAZON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-1002
Mailing Address - Country:US
Mailing Address - Phone:858-859-5181
Mailing Address - Fax:
Practice Address - Street 1:11126 ALMAZON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-1002
Practice Address - Country:US
Practice Address - Phone:858-859-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman