=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609854249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROME EDWARD BAGNER DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 10/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 HEMPSTEAD AVE STE 158
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-764-6800
-----------------------------------------------------
Fax | 516-764-7047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 HEMPSTEAD AVE STE 158
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-764-6800
-----------------------------------------------------
Fax | 516-764-7047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 0022331
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------