Healthcare Provider Details

I. General information

NPI: 1730411430
Provider Name (Legal Business Name): NICHOLAS G. BAGNOLI DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 03/25/2010
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 Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS G BAGNOLI
Title or Position: OWNER
Credential: MD
Phone: 407-210-4251