1679643183 NPI number — DEMETRIO J AGCAOILI MD LLC

Table of content: (NPI 1679643183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679643183 NPI number — DEMETRIO J AGCAOILI MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEMETRIO J AGCAOILI MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679643183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51520 NATIONAL ROAD E
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
SAINTCLAIRSVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43950-8213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-296-5931
Provider Business Mailing Address Fax Number:
740-296-5942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51520 NATIONAL ROAD E
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
SAINTCLAIRSVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43950-8213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-296-5931
Provider Business Practice Location Address Fax Number:
740-296-5942
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AGCAOILI
Authorized Official First Name:
DEMETRIO
Authorized Official Middle Name:
JOSE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
740-695-3703

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  35083354 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1841957000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2413267 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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