Provider Demographics
NPI:1851698633
Name:AGABA, EMMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:AGABA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:740-434-0565
Practice Address - Fax:740-434-0563
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048527208600000X
OH35.122778208600000X
NY61003921208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01305917OtherRAILROAD MEDICARE - MHCPI
WV3910000891Medicaid
OH0096841Medicaid
OHH266360Medicare PIN
OHP01305917OtherRAILROAD MEDICARE - MHCPI