Healthcare Provider Details

I. General information

NPI: 1568424356
Provider Name (Legal Business Name): JOHN CLAUDE BAGWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 HOSPITAL DR
RATON NM
87740-2012
US

IV. Provider business mailing address

490A W ZIA RD
SANTA FE NM
87505-6996
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-7739
  • Fax:
Mailing address:
  • Phone: 505-913-8900
  • Fax: 505-913-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberD3140
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number070527
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number91-4
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: