Basic Information
| Provider Information | |||||||||
| NPI: | 1104842061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGAE | ||||||||
| FirstName: | SOLOMON | ||||||||
| MiddleName: | DAFFO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 COLEGATE DR BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457509549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405684814 | ||||||||
| FaxNumber: | 7403743165 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MATTHEW ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405685207 | ||||||||
| FaxNumber: | 7405685297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35.128475 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 001293 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02116681 | 05 | NY | MEDICAID |