Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 4030063912 | MI |
N | 207VG0400X | Gynecologist | 4030063912 | MI |
NPI | 1023118809 |
---|---|
Provider Name | Dr. Obioma S Agomuoh |
First Address | Southfield, MI 48076-4957 |
Second Address | Hamtramck, MI 48212-9802 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 10/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4149140 | (05) | MI |
F54726 | (02) | MI |