Provider Demographics
NPI:1467534198
Name:RUBEN T AGRA MD AND LOLITA R. AGRA MD
Entity Type:Organization
Organization Name:RUBEN T AGRA MD AND LOLITA R. AGRA MD
Other - Org Name:OLYMPIA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOLITA
Authorized Official - Middle Name:R
Authorized Official - Last Name:AGRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-441-0660
Mailing Address - Street 1:PO BOX 770502
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-0027
Mailing Address - Country:US
Mailing Address - Phone:440-930-0609
Mailing Address - Fax:440-653-9889
Practice Address - Street 1:3361 E 55TH STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1547
Practice Address - Country:US
Practice Address - Phone:216-441-0660
Practice Address - Fax:216-441-7261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0719824Medicaid
C02322Medicare UPIN
OHAGMedicare ID - Type Unspecified