Provider Demographics
NPI:1902043060
Name:ADESUBOMI AGORO M.D. P.A.
Entity Type:Organization
Organization Name:ADESUBOMI AGORO M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADESUBOMI
Authorized Official - Middle Name:B
Authorized Official - Last Name:AGORO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-763-5550
Mailing Address - Street 1:PO BOX 150929
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-0929
Mailing Address - Country:US
Mailing Address - Phone:817-763-5550
Mailing Address - Fax:817-763-5715
Practice Address - Street 1:1339 EAST ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-4228
Practice Address - Country:US
Practice Address - Phone:817-763-5550
Practice Address - Fax:817-763-5715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2394207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK2394OtherSTATE LICENSE