Provider Demographics
NPI:1275728529
Name:AGBO, OSMUND UGOCHUKWU (MD)
Entity Type:Individual
Prefix:DR
First Name:OSMUND
Middle Name:UGOCHUKWU
Last Name:AGBO
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 1:1073 SING SING RD
Mailing Address - Street 2:APT. C1
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1389
Mailing Address - Country:US
Mailing Address - Phone:469-417-7569
Mailing Address - Fax:877-929-4871
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:347-804-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2359207L00000X, 207RC0200X
KY45748207R00000X
NC200701973207RC0200X, 207RP1001X
NY251622207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921995Medicaid
NCNCA103AOtherMEDICARE PTAN, INDIVIDUAL FOR CMC-NORTHEAST
NCNCA103AOtherMEDICARE PTAN, INDIVIDUAL FOR CMC-NORTHEAST