Provider Demographics
NPI:1831473354
Name:CORNELIA L AGENT MD PA
Entity Type:Organization
Organization Name:CORNELIA L AGENT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:AGENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-331-5253
Mailing Address - Street 1:215 W BLACKSTONE LN
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-3407
Mailing Address - Country:US
Mailing Address - Phone:281-331-5253
Mailing Address - Fax:281-585-4074
Practice Address - Street 1:215 W BLACKSTONE LN
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-3407
Practice Address - Country:US
Practice Address - Phone:281-331-5253
Practice Address - Fax:281-585-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114075801Medicaid
TX114075801Medicaid