Provider Demographics
NPI:1154742963
Name:AGBAJE, KAZIM
Entity type:Individual
Prefix:
First Name:KAZIM
Middle Name:
Last Name:AGBAJE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 CHRISTY WAY
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-2629
Mailing Address - Country:US
Mailing Address - Phone:619-764-0150
Mailing Address - Fax:
Practice Address - Street 1:3111 CHRISTY WAY
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-2629
Practice Address - Country:US
Practice Address - Phone:619-764-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04177814246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory