Provider Demographics
NPI:1992756159
Name:BAGG, CHAD A (OD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:A
Last Name:BAGG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 24TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6365
Mailing Address - Country:US
Mailing Address - Phone:405-329-3937
Mailing Address - Fax:405-329-3556
Practice Address - Street 1:1021 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6365
Practice Address - Country:US
Practice Address - Phone:405-329-3937
Practice Address - Fax:405-329-3556
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
241332202OtherGROUP PTAN
242334601OtherINDIVIDUAL PTAN
OK5033820001OtherCIGNA DMEC
OK200016870AMedicaid
242334601OtherINDIVIDUAL PTAN
OK200016870AMedicaid