Provider Demographics
NPI:1669689600
Name:AGIN, TERRY (RDO)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:AGIN
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3293
Mailing Address - Country:US
Mailing Address - Phone:805-481-9797
Mailing Address - Fax:805-481-1429
Practice Address - Street 1:889 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3293
Practice Address - Country:US
Practice Address - Phone:805-481-9797
Practice Address - Fax:805-481-1429
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL1015156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0725720001Medicare NSC