Provider Demographics
NPI:1518971852
Name:AGBEMABIESE, CHARLES KOFI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KOFI
Last Name:AGBEMABIESE
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:PO BOX 60516
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1213 LEXINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3416
Practice Address - Country:US
Practice Address - Phone:336-481-1950
Practice Address - Fax:336-277-8805
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434169207RH0003X, 207RX0202X, 207RH0000X
NC2019-00999207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG99309Medicare UPIN
PA1021840170001Medicaid
PA129410Medicare PIN
PAP00657250Medicare PIN
PA823389OtherFIRST PRIORITY HEALTH
DCJ443-0014OtherCAREFIRST BLUE SHIELD
PA2071682OtherHIGHMARK BLUE SHIELD
DCP00349245OtherRAIL ROAD MEDICARE
DC037484700Medicaid
DC018824M28Medicare PIN