Provider Demographics
NPI:1124022108
Name:AGCAOILI, JACQUELINE GESNER (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GESNER
Last Name:AGCAOILI
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 507
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501
Mailing Address - Country:US
Mailing Address - Phone:951-369-6191
Mailing Address - Fax:951-369-0304
Practice Address - Street 1:4440 BROCKTON AVE.
Practice Address - Street 2:SUITE 320
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-369-6191
Practice Address - Fax:951-369-0304
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2020-03-11
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAA46231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E38303Medicare UPIN