Provider Demographics
NPI:1457317307
Name:AGBOGU, BOB (MD)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:
Last Name:AGBOGU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1136 CLEVELAND AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3618
Mailing Address - Country:US
Mailing Address - Phone:404-669-9669
Mailing Address - Fax:404-699-9668
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:STE 305
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-669-9669
Practice Address - Fax:404-699-9668
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA043839207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00789456AMedicaid
GA00789456AMedicaid
GAF71741Medicare UPIN