Healthcare Provider Details

I. General information

NPI: 1619956406
Provider Name (Legal Business Name): AGNES T OGENA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD,ATTN:MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR NMCSD,ATTN:MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6460
  • Fax: 619-532-6299
Mailing address:
  • Phone: 619-532-6460
  • Fax: 619-532-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA36460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: