Provider Demographics
NPI:1346311404
Name:AGNONE, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:AGNONE
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 1:1340 BROAD AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2404
Mailing Address - Country:US
Mailing Address - Phone:228-575-1500
Mailing Address - Fax:
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-575-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003000089174400000X
MS20943208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149403001Medicaid
MS09206796Medicaid
MO208427401Medicaid
AR149403001Medicaid