Provider Demographics
NPI:1649217191
Name:AGENT, JOHN P (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:AGENT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776075
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6075
Mailing Address - Country:US
Mailing Address - Phone:918-774-0034
Mailing Address - Fax:
Practice Address - Street 1:1015 E CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5011
Practice Address - Country:US
Practice Address - Phone:918-774-0034
Practice Address - Fax:918-774-0650
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1152207R00000X
OK3341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110222385OtherRAILROAD MEDICARE
AR145013003Medicaid
ARG31188Medicare UPIN
AR5L947Medicare ID - Type Unspecified