Provider Demographics
NPI:1649207515
Name:SO, AGNES L (MD)
Entity Type:Individual
Prefix:MS
First Name:AGNES
Middle Name:L
Last Name:SO
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 1:863 50TH ST
Mailing Address - Street 2:SUITE M5
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-6877
Mailing Address - Country:US
Mailing Address - Phone:718-686-8880
Mailing Address - Fax:
Practice Address - Street 1:863 50TH ST
Practice Address - Street 2:2ND FL SUITE M5
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-6877
Practice Address - Country:US
Practice Address - Phone:718-686-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213474-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01988903Medicaid
NY01988903Medicaid
583151Medicare ID - Type Unspecified