Provider Demographics
NPI:1942298104
Name:BAGNALL, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:BAGNALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MAIN ST 107
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6766
Mailing Address - Country:US
Mailing Address - Phone:716-906-5908
Mailing Address - Fax:
Practice Address - Street 1:3925 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1718
Practice Address - Country:US
Practice Address - Phone:716-250-6545
Practice Address - Fax:716-250-6566
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199397-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010007802OtherUNIVERAHEALTHCARE
NY000523745005OtherBLUE CROSS/COMMUNITY BLUE
NY3007272OtherINDEPENDENT HEALTH
NYDD1819Medicare ID - Type Unspecified
NY00010007802OtherUNIVERAHEALTHCARE