MEDICARE: DR. BRIAN WITTMUS ZAGOL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	0101234822	VA
2	207RC0000X	Cardiovascular Disease Physician	39369	TN
3	390200000X	Student in an Organized Health Care Education/Training Program		VA
4	207RI0011X	Interventional Cardiology Physician	0101234822	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4121983	OTHER	TN	BLUE CROSS

General Provider Information

NPI Number	:	1902901556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN WITTMUS ZAGOL MD

Provider Business Mailing Address
First Line	:	201 S MAIN ST STE 1100
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-2938
Country	:	US
Telephone Number	:	434-791-1088
Fax Number	:

Provider Business Practice Location Address
First Line	:	158 EXECUTIVE DR
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-4100
Country	:	US
Telephone Number	:	434-791-1088
Fax Number	:	434-799-8525

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	11/06/2022

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