Provider Demographics
NPI:1053505743
Name:AGERSBORG, SALLY S (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:S
Last Name:AGERSBORG
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 947365
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2478
Practice Address - Country:US
Practice Address - Phone:949-540-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35178207ZH0000X
NJ25MA09454000207ZH0000X
NY263526207ZH0000X
NE36038207ZH0000X
WAMD61433822207ZH0000X
FLME103427207ZH0000X
TXN1972207ZH0000X
PAMD432959207ZH0000X
CAA82499207ZH0000X
MDD0066759207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI30493Medicare UPIN