Healthcare Provider Details

I. General information

NPI: 1588942155
Provider Name (Legal Business Name): FREDERICK BAGARES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4176 S PLAZA TRL STE 218
VIRGINIA BEACH VA
23452-1920
US

IV. Provider business mailing address

2085 LYNNHAVEN PKWY STE 106
VIRGINIA BCH VA
23456-1497
US

V. Phone/Fax

Practice location:
  • Phone: 757-828-3080
  • Fax: 757-828-3083
Mailing address:
  • Phone: 757-828-3080
  • Fax: 757-828-3083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0102204441
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0102204441
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: