MEDICARE: EFREN C AGANON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	35077098	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1184652539	OTHER	OH	GROUP TAX ID
4	9934723	OTHER	OH	GROUP PTAN

General Provider Information

NPI Number	:	1184629214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EFREN C AGANON MD

Provider Business Mailing Address
First Line	:	200 SAINT CLAIR AVE
Second Line	:	JTDM FAMILY PRACTICE, LLC
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2400
Country	:	US
Telephone Number	:	419-394-3387
Fax Number	:	419-394-9580

Provider Business Practice Location Address
First Line	:	1010 HAGER ST
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2421
Country	:	US
Telephone Number	:	419-394-9579
Fax Number	:	419-394-9580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/21/2022

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Directions to “ EFREN C AGANON MD” Practice Location

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