Healthcare Provider Details

I. General information

NPI: 1891856373
Provider Name (Legal Business Name): LAWRENCE Y. C. AGODOA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 TAYLOR RD 4650 TAYLOR ROAD BLDG 17A RM 3019
BETHESDA MD
20889-5638
US

IV. Provider business mailing address

13217 GLENHILL RD
SILVER SPRING MD
20904-3260
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-6462
  • Fax: 202-782-0185
Mailing address:
  • Phone: 301-384-9386
  • Fax: 301-594-9358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD0035131
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberD0035131
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: