Provider Demographics
NPI:1265660856
Name:AGHA, MOHAMMAD TARIQ (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:TARIQ
Last Name:AGHA
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:DEPARTMENT OF PM&R
Mailing Address - Street 2:1 HOSPITAL DRIVE, DC046.00
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-0001
Mailing Address - Country:US
Mailing Address - Phone:573-882-3101
Mailing Address - Fax:573-884-4540
Practice Address - Street 1:DEPARTMENT OF PM&R
Practice Address - Street 2:1 HOSPITAL DRIVE, DC046.00
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-3101
Practice Address - Fax:573-884-4540
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2014-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116022337390200000X
390200000X
MO2014013909208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program