Provider Demographics
NPI:1902901556
Name:ZAGOL, BRIAN WITTMUS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WITTMUS
Last Name:ZAGOL
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 1:201 S MAIN ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2938
Mailing Address - Country:US
Mailing Address - Phone:434-791-1088
Mailing Address - Fax:
Practice Address - Street 1:158 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4100
Practice Address - Country:US
Practice Address - Phone:434-791-1088
Practice Address - Fax:434-799-8525
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234822207RC0000X, 207RI0011X
TN39369207RC0000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3337419Medicaid
TN4121983OtherBLUE CROSS
I51371Medicare UPIN
TN3337419Medicaid