Basic Information
| Provider Information | |||||||||
| NPI: | 1902833627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAGEFORDE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FINE | ||||||||
| OtherFirstName: | GRETCHEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CREDNTLG COORDINATOR | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725395 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 DUTCHMANS LN STE 101 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028962120 | ||||||||
| FaxNumber: | 5028962110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 20071 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 50031154 | 01 | KY | PASSPORT & PASSPORT ADVTG - NCVA | OTHER | P00889587 | 01 | KY | MEDICARE RR - NCVA | OTHER | 1056110 | 01 | KY | PASSPORT PIN | OTHER | 000000693027 | 01 | KY | ANTHEM - NCVA | OTHER | 64200710 | 05 | KY | MEDICAID | 100388760F | 05 | IN | MEDICAID | 060018530 | 01 | KY | RAILROAD MEDICARE PIN | OTHER | 000000044911 | 01 | KY | ANTHEM PIN | OTHER | 000057080C | 01 | KY | HUMANA - NCVA | OTHER | 0203578000 | 01 | KY | PASSPORT ADVANAGE PIN | OTHER | 100388760A | 05 | IN | MEDICAID |