Provider Demographics
NPI:1386938058
Name:AGBANYIM, GABRIEL (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:AGBANYIM
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:1110 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1602
Practice Address - Country:US
Practice Address - Phone:443-351-3917
Practice Address - Fax:443-351-3918
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD352504ZDDBMedicare PIN
MD352504YVZMedicare PIN
MD325336YWV2Medicare PIN