Healthcare Provider Details

I. General information

NPI: 1346508249
Provider Name (Legal Business Name): KENNETH ARTHUR BAGWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 STRAWBERRY HILL CT STE 4
STAMFORD CT
06902-2594
US

IV. Provider business mailing address

2450 NE MARY ROSE PL STE 120
BEND OR
97701-7132
US

V. Phone/Fax

Practice location:
  • Phone: 203-353-0000
  • Fax: 203-357-8109
Mailing address:
  • Phone: 541-312-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number83331
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD182448
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: