Provider Demographics
NPI:1538579263
Name:BAGARAZZI, MARK LEONARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEONARD
Last Name:BAGARAZZI
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 1:280 GARRISON WAY
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2546
Mailing Address - Country:US
Mailing Address - Phone:610-527-8997
Mailing Address - Fax:
Practice Address - Street 1:280 GARRISON WAY
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-2546
Practice Address - Country:US
Practice Address - Phone:610-527-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047811L2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases