Provider Demographics
NPI:1841243839
Name:AGPOON MEDICAL CLINIC, S.C.
Entity Type:Organization
Organization Name:AGPOON MEDICAL CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:AGPOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-544-9680
Mailing Address - Street 1:1859 E MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-3915
Mailing Address - Country:US
Mailing Address - Phone:262-544-9680
Mailing Address - Fax:262-544-1659
Practice Address - Street 1:1859 E MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-3915
Practice Address - Country:US
Practice Address - Phone:262-544-9680
Practice Address - Fax:262-544-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18704261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTIN