Provider Demographics
NPI: | 1164420741 |
---|---|
Name: | AGHA, SYED A (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SYED |
Middle Name: | A |
Last Name: | AGHA |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | ABBAS |
Other - Middle Name: | |
Other - Last Name: | AGHA |
Other - Suffix: | |
Other - Last Name Type: | Professional Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 2292 CHAMBLISS AVE NW STE F |
Mailing Address - Street 2: | |
Mailing Address - City: | CLEVELAND |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37311-3862 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-919-1577 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2292 CHAMBLISS AVE NW STE F |
Practice Address - Street 2: | |
Practice Address - City: | CLEVELAND |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37311-3862 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-919-1577 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-08 |
Last Update Date: | 2022-11-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | N2899 | 207RI0011X |
GA | 59357 | 207RI0011X |
TN | 55598 | 207RI0011X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 091420207 | Medicaid | |
GA | 091420207 | Medicaid | |
OK | 244305202 | Medicare ID - Type Unspecified | DR. AGHA MEDICARE # |