Provider Demographics
NPI:1285702894
Name:UBANI, AGNES (MD)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:UBANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AGNES
Other - Middle Name:
Other - Last Name:UBANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:INC
Mailing Address - Street 1:PO BOX 16722
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33687-6722
Mailing Address - Country:US
Mailing Address - Phone:813-341-7900
Mailing Address - Fax:813-341-7903
Practice Address - Street 1:11434 N 53RD STREET
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-4071
Practice Address - Country:US
Practice Address - Phone:813-341-7900
Practice Address - Fax:813-341-7903
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 84332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264702800Medicaid
FL1285702894OtherK7030
FLK7030Other1285702894
FL1285702894OtherK7030
FL62817WMedicare PIN
FLH71361Medicare UPIN