MEDICARE: RUBEN T AGRA MD AND LOLITA R. AGRA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35034511	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467534198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUBEN T AGRA MD AND LOLITA R. AGRA MD

Provider Business Mailing Address
First Line	:	PO BOX 770502
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-0027
Country	:	US
Telephone Number	:	440-930-0609
Fax Number	:	440-653-9889

Provider Business Practice Location Address
First Line	:	3361 E 55TH STREET
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44127-1547
Country	:	US
Telephone Number	:	216-441-0660
Fax Number	:	216-441-7261

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	LOLITA R AGRA
Credential	:	MD
Telephone Number	:	216-441-0660

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	10/01/2015

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