Provider Demographics
NPI:1538155411
Name:BAGLEY, DOUGLAS K (PT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 207
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-375-4263
Practice Address - Fax:801-429-8085
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121795-24012251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT77717OtherPEHP
UT6400377OtherUNITED HEALTHCARE
UT0224632005OtherCIGNA
UT005569406Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER