Provider Demographics
NPI:1154898146
Name:AGODU, ISRAEL
Entity type:Individual
Prefix:
First Name:ISRAEL
Middle Name:
Last Name:AGODU
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 1:6474 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-4754
Mailing Address - Country:US
Mailing Address - Phone:313-441-5212
Mailing Address - Fax:
Practice Address - Street 1:6474 ROSEMONT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-4754
Practice Address - Country:US
Practice Address - Phone:313-441-5212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor