Provider Demographics
NPI:1760988356
Name:AGBONHESE, RACHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:K
Last Name:AGBONHESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:K
Other - Last Name:WOJNOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1095 BROAD RIPPLE AVE STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2381
Practice Address - Country:US
Practice Address - Phone:317-621-3680
Practice Address - Fax:317-621-3689
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086654A207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00344277OtherRAILROAD MEDICARE