Provider Demographics
NPI:1467633727
Name:AGRA, LOLITA R (MD)
Entity Type:Individual
Prefix:
First Name:LOLITA
Middle Name:R
Last Name:AGRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3361 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44127-1547
Mailing Address - Country:US
Mailing Address - Phone:216-441-0660
Mailing Address - Fax:216-883-3335
Practice Address - Street 1:3361 E 55TH ST
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:216-883-3335
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03354511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0186758Medicaid
OH9926401OtherMEDICARE GROUP
OH9926401OtherMEDICARE GROUP