Basic Information
| Provider Information | |||||||||
| NPI: | 1760626279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGBAERE | ||||||||
| FirstName: | ALPHONSUS | ||||||||
| MiddleName: | MADUWUBA | ||||||||
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| Credential: | MT(ASCP)CLS(NCA) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 COLUMBIA DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300327206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042862838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246RM2200X | 163311 | GA | N | Technologists, Technicians & Other Technical Service Providers | Technician, Pathology | Medical Laboratory | 247ZC0005X | 163311 | GA | Y | Technologists, Technicians & Other Technical Service Providers | Pathology | Clinical Laboratory Director, Non-physician |
No ID Information.