Provider Demographics
NPI:1902028871
Name:OVIENMHADA, AGNES O (MD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:O
Last Name:OVIENMHADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8620 N 22ND AVE
Mailing Address - Street 2:200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021
Mailing Address - Country:US
Mailing Address - Phone:602-674-6506
Mailing Address - Fax:602-674-6512
Practice Address - Street 1:5102 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031
Practice Address - Country:US
Practice Address - Phone:623-848-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37916207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ367600Medicaid
AZZ131142Medicare PIN