Provider Demographics
NPI:1831190172
Name:AGBODZA, KWAMI DELALI (MD)
Entity type:Individual
Prefix:DR
First Name:KWAMI
Middle Name:DELALI
Last Name:AGBODZA
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 1:15 WESTLAKE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-5160
Mailing Address - Country:US
Mailing Address - Phone:732-961-6453
Mailing Address - Fax:732-961-6453
Practice Address - Street 1:15 WESTLAKE CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-5160
Practice Address - Country:US
Practice Address - Phone:732-961-6453
Practice Address - Fax:732-961-6453
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500799207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6420109Medicaid
NJ601825Medicare ID - Type Unspecified
NJ6420109Medicaid