Provider Demographics
NPI:1609864446
Name:AGUNOBI, CHARLES K (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:K
Last Name:AGUNOBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3099 BRECKINRIDGE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1011
Mailing Address - Country:US
Mailing Address - Phone:678-242-8035
Mailing Address - Fax:678-373-1645
Practice Address - Street 1:3099 BRECKINRIDGE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1011
Practice Address - Country:US
Practice Address - Phone:678-242-8035
Practice Address - Fax:678-373-1645
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400694207R00000X, 208M00000X
SC20751208M00000X
GA38161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0069AMedicaid
NC8910429Medicaid
NC2230841EMedicare ID - Type Unspecified