Healthcare Provider Details

I. General information

NPI: 1740423417
Provider Name (Legal Business Name): TINA A AGBAOSI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 MADISON AVE
MEMPHIS TN
38103-3409
US

IV. Provider business mailing address

6255 W SUNSET BLVD FL 21
LOS ANGELES CA
90028-7422
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-6969
  • Fax: 901-545-6424
Mailing address:
  • Phone: 323-860-5200
  • Fax: 323-467-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number47524
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.015230
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: