Healthcare Provider Details

I. General information

NPI: 1356907620
Provider Name (Legal Business Name): KIMBERLEY C AGBO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 FRANKLIN CORNER RD STE 214
LAWRENCEVILLE NJ
08648-2526
US

IV. Provider business mailing address

175 MOUNTAINVIEW AVE
SCOTCH PLAINS NJ
07076-1444
US

V. Phone/Fax

Practice location:
  • Phone: 609-537-7200
  • Fax: 609-303-4191
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MB11862300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: