Provider Demographics
NPI:1467446682
Name:AGUBOSIM, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:AGUBOSIM
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 1:1574 HENTHORNE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1397
Mailing Address - Country:US
Mailing Address - Phone:419-794-1170
Mailing Address - Fax:
Practice Address - Street 1:1574 HENTHORNE DR
Practice Address - Street 2:SUITE C
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1397
Practice Address - Country:US
Practice Address - Phone:419-794-1170
Practice Address - Fax:419-794-1171
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074877207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000220323OtherANTHEM
OH2132187Medicaid
OHP00694361OtherMEDICARE RAILROAD
OH2873887Medicaid
OHP00694361OtherMEDICARE RAILROAD
G91840Medicare UPIN