Healthcare Provider Details

I. General information

NPI: 1134707045
Provider Name (Legal Business Name): JACKSON PHILIP BAGBY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CAHILL RD STE 206
BRANSON MO
65616-1911
US

IV. Provider business mailing address

121 CAHILL RD STE 206
BRANSON MO
65616-1911
US

V. Phone/Fax

Practice location:
  • Phone: 417-348-8100
  • Fax:
Mailing address:
  • Phone: 417-348-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2020235730
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2022035730
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: