Provider Demographics
NPI:1538506266
Name:AGISIM, MIRIAM (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:AGISIM
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 1:8935 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1938
Mailing Address - Country:US
Mailing Address - Phone:503-772-4335
Mailing Address - Fax:503-772-4337
Practice Address - Street 1:8935 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1938
Practice Address - Country:US
Practice Address - Phone:503-772-4335
Practice Address - Fax:503-772-4337
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD179807207Q00000X
PAMT204726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine