Provider Demographics
NPI:1194774604
Name:AGAMASU, JACOB K (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:K
Last Name:AGAMASU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 STIRLING CENTER PL UNIT 1911
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5209
Mailing Address - Country:US
Mailing Address - Phone:407-804-9616
Mailing Address - Fax:407-804-8331
Practice Address - Street 1:731 STIRLING CENTER PL UNIT 1911
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5209
Practice Address - Country:US
Practice Address - Phone:407-804-9616
Practice Address - Fax:407-804-8331
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85101207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13045OtherBC
FL13045ZMedicare ID - Type Unspecified
FL13045OtherBC