Provider Demographics
NPI:1053678664
Name:NAMBIRO-KASOLO, AGNES (MD)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:NAMBIRO-KASOLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AGNES
Other - Middle Name:
Other - Last Name:NAMBIRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-838-8824
Practice Address - Fax:770-838-8922
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA073901207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist