Healthcare Provider Details

I. General information

NPI: 1205891744
Provider Name (Legal Business Name): AGNES C BACALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12546 E US HIGHWAY 50
LOOGOOTEE IN
47553-5220
US

IV. Provider business mailing address

PO BOX 760
WASHINGTON IN
47501-0760
US

V. Phone/Fax

Practice location:
  • Phone: 812-295-5095
  • Fax: 812-295-9403
Mailing address:
  • Phone: 812-254-2760
  • Fax: 812-254-8636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32413
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01043434A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: