Provider Demographics
NPI:1194728964
Name:AGNER, CELSO (MD, MSC)
Entity type:Individual
Prefix:DR
First Name:CELSO
Middle Name:
Last Name:AGNER
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:DR
Other - First Name:CELSO
Other - Middle Name:
Other - Last Name:AGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 SE 3RD AVENUE
Practice Address - Street 2:SUITE 623
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-320-3322
Practice Address - Fax:954-462-7410
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2273952084N0400X
IL036-1164082084N0400X
FLME 1171532084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14U19OtherFLORIDA BLUE (BCBS)
FL010834000Medicaid
NY02408684Medicaid
IL695540001OtherPTAN
FL14U19OtherFLORIDA BLUE (BCBS)
FL010834000Medicaid
IL695540001OtherPTAN