Provider Demographics
NPI:1598719791
Name:AGRA, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:AGRA
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 1:3938 SUNBEAM DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:5606
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-989-6107
Practice Address - Fax:213-483-5032
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54058174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A540581Medicaid
CAG42563Medicare UPIN
CA00A540581Medicaid