Healthcare Provider Details

I. General information

NPI: 1043228224
Provider Name (Legal Business Name): ELMO MICHAEL AGATEP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19582 BEACH BLVD STE 219
HUNTINGTON BEACH CA
92648-5923
US

IV. Provider business mailing address

19582 BEACH BLVD STE 219
HUNTINGTON BEACH CA
92648-5923
US

V. Phone/Fax

Practice location:
  • Phone: 714-477-8190
  • Fax: 714-477-8191
Mailing address:
  • Phone: 714-477-8190
  • Fax: 714-477-8191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA85575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: