Provider Demographics
NPI:1457452526
Name:AGENT, CORNELIA LOUISE (MD PA)
Entity Type:Individual
Prefix:DR
First Name:CORNELIA
Middle Name:LOUISE
Last Name:AGENT
Suffix:
Gender:F
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W BLACKSTONE LN
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-3407
Mailing Address - Country:US
Mailing Address - Phone:281-331-5253
Mailing Address - Fax:281-585-4074
Practice Address - Street 1:215 W BLACKSTONE LN
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-3407
Practice Address - Country:US
Practice Address - Phone:281-331-5253
Practice Address - Fax:281-585-4074
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114075801Medicaid
TX114075801Medicaid
TX00B19FMedicare ID - Type Unspecified