Healthcare Provider Details

I. General information

NPI: 1467014449
Provider Name (Legal Business Name): SARAH MELISSA AGBADA POLISTICO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH MELISSA BARBONO AGBADA MD

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 STATE ST
LA PORTE IN
46350-3115
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 219-324-3431
  • Fax: 219-362-3802
Mailing address:
  • Phone: 219-364-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01085776A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: