Healthcare Provider Details

I. General information

NPI: 1588994875
Provider Name (Legal Business Name): ADESUBOMI AGORO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PENNSYLVANIA AVENUE
FORT WORTH TX
76104-2120
US

IV. Provider business mailing address

1100 PENNSYLVANIA AVENUE
FORT WORTH TX
76104-2120
US

V. Phone/Fax

Practice location:
  • Phone: 817-763-5550
  • Fax: 817-763-5715
Mailing address:
  • Phone: 817-763-5550
  • Fax: 817-763-5715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberK2394
License Number StateTX

VIII. Authorized Official

Name: ADESUBOMI AGORO
Title or Position: OWNER
Credential:
Phone: 817-763-5550