Provider Demographics
NPI:1508879164
Name:DAGOGO-JACK, AGBANI IBINABO (MD)
Entity Type:Individual
Prefix:DR
First Name:AGBANI
Middle Name:IBINABO
Last Name:DAGOGO-JACK
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 1:9636 MOURNING DOVE CV
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-5668
Mailing Address - Country:US
Mailing Address - Phone:901-271-4900
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD108333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine