Healthcare Provider Details

I. General information

NPI: 1598719411
Provider Name (Legal Business Name): NICHOLAS G. BAGNOLI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NICHOLAS G BAGNOLI DO

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SLIGH BLVD
ORLANDO FL
32806-1108
US

IV. Provider business mailing address

3869 WINDERLAKES DR
ORLANDO FL
32835-2625
US

V. Phone/Fax

Practice location:
  • Phone: 407-210-4251
  • Fax: 407-648-0968
Mailing address:
  • Phone: 407-210-4251
  • Fax: 407-648-0968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS7417
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: