1467014449 NPI number — DR. SARAH MELISSA AGBADA POLISTICO MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467014449 NPI number — DR. SARAH MELISSA AGBADA POLISTICO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLISTICO
Provider First Name:
SARAH MELISSA
Provider Middle Name:
AGBADA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGBADA
Provider Other First Name:
SARAH MELISSA
Provider Other Middle Name:
BARBONO
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467014449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2022 KELLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46304-8708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-364-4004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1509 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-3115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-324-3431
Provider Business Practice Location Address Fax Number:
219-362-3802
Provider Enumeration Date:
07/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 01085776A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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