Healthcare Provider Details

I. General information

NPI: 1053505743
Provider Name (Legal Business Name): SALLY S AGERSBORG M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 02/09/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 TECHNOLOGY DR
IRVINE CA
92618-2478
US

IV. Provider business mailing address

PO BOX 947365
ATLANTA GA
30394-7365
US

V. Phone/Fax

Practice location:
  • Phone: 949-540-9421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number35178
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number25MA09454000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number263526
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number36038
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberMD61433822
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberME103427
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberN1972
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberMD432959
License Number StatePA
# 9
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberA82499
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberD0066759
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: