Provider Demographics
NPI:1972575439
Name:AGOLIA, RANDY (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:AGOLIA
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 505436
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5436
Mailing Address - Country:US
Mailing Address - Phone:636-344-3333
Mailing Address - Fax:636-344-3334
Practice Address - Street 1:20 PROGRESS POINT PKWY
Practice Address - Street 2:STE 22
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2206
Practice Address - Country:US
Practice Address - Phone:636-344-3333
Practice Address - Fax:636-344-3334
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200026270Medicaid