Provider Demographics
NPI:1003863135
Name:AGOCHA, AUGUSTINE ENYINNA (MD)
Entity Type:Individual
Prefix:DR
First Name:AUGUSTINE
Middle Name:ENYINNA
Last Name:AGOCHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MEDICAL PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4696
Mailing Address - Country:US
Mailing Address - Phone:813-497-9661
Mailing Address - Fax:813-615-8468
Practice Address - Street 1:3000 MEDICAL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4696
Practice Address - Country:US
Practice Address - Phone:813-497-9661
Practice Address - Fax:813-615-8468
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111542207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC315723Medicaid
FL004434500Medicaid
NJ7716800Medicaid
SC315723Medicaid
FLFT225ZMedicare PIN
FL004434500Medicaid
NJG80972Medicare UPIN
FL004434500Medicaid