Provider Demographics
NPI:1760626279
Name:AGBAERE, ALPHONSUS MADUWUBA (MT(ASCP)CLS(NCA))
Entity Type:Individual
Prefix:
First Name:ALPHONSUS
Middle Name:MADUWUBA
Last Name:AGBAERE
Suffix:
Gender:M
Credentials:MT(ASCP)CLS(NCA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-7206
Mailing Address - Country:US
Mailing Address - Phone:404-286-2838
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA163311246RM2200X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory