Provider Demographics
NPI:1093820508
Name:CHUKWUMERIJE, AGATHA A (MD)
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:A
Last Name:CHUKWUMERIJE
Suffix:
Gender:F
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:PO BOX 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708
Mailing Address - Country:US
Mailing Address - Phone:330-833-5530
Mailing Address - Fax:330-833-6085
Practice Address - Street 1:1930 FULTON RD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3526
Practice Address - Country:US
Practice Address - Phone:330-454-9766
Practice Address - Fax:330-454-3438
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067956207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121988Medicaid
OH0121988Medicaid
G04663Medicare UPIN