Provider Demographics
NPI:1073583076
Name:AGORO, ADESUBOMI (MD)
Entity Type:Individual
Prefix:DR
First Name:ADESUBOMI
Middle Name:
Last Name:AGORO
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 1:1100 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2120
Mailing Address - Country:US
Mailing Address - Phone:817-763-5550
Mailing Address - Fax:817-870-1280
Practice Address - Street 1:1100 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2120
Practice Address - Country:US
Practice Address - Phone:817-763-5550
Practice Address - Fax:817-870-1280
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2394207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045359901Medicaid
TX045359901Medicaid
TX8F9578Medicare PIN
TXG08509Medicare UPIN
TX8L0613Medicare PIN