Healthcare Provider Details

I. General information

NPI: 1144217860
Provider Name (Legal Business Name): FELICITAS G AGANA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RIDGEWOOD AVE
HOLLY HILL FL
32117-2320
US

IV. Provider business mailing address

PO BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 386-676-7100
  • Fax:
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0068955
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: