Provider Demographics
NPI:1639212574
Name:JACQUELINE G. AGCAOILI, MD CORPORATION
Entity Type:Organization
Organization Name:JACQUELINE G. AGCAOILI, MD CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:GESNER
Authorized Official - Last Name:AGCAOILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-369-6191
Mailing Address - Street 1:4440 BROCKTON AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4068
Mailing Address - Country:US
Mailing Address - Phone:951-369-6191
Mailing Address - Fax:951-369-0304
Practice Address - Street 1:4440 BROCKTON AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4068
Practice Address - Country:US
Practice Address - Phone:951-369-6191
Practice Address - Fax:951-369-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A462310Medicaid
CA00A462310Medicaid
CAE38303Medicare UPIN