Provider Demographics
NPI:1184620981
Name:BAGLEY, DANE W (OD)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:W
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6945 UNIVERSITY DR NW STE G
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-1789
Mailing Address - Country:US
Mailing Address - Phone:256-325-6950
Mailing Address - Fax:
Practice Address - Street 1:6945 UNIVERSITY DR NW STE G
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-1789
Practice Address - Country:US
Practice Address - Phone:256-325-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2012-07-12
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
ALS-981-TA-566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU88206Medicare UPIN
AL051524442BAGMedicare ID - Type Unspecified
AL5526440001Medicare NSC