Provider Demographics
NPI:1902097652
Name:AGAHAN, MARGIE A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARGIE
Middle Name:A
Last Name:AGAHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MARGIE
Other - Middle Name:ASDILLA
Other - Last Name:AGAHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:236 KALAMSA MACHECHE
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96921
Mailing Address - Country:US
Mailing Address - Phone:671-649-0600
Mailing Address - Fax:
Practice Address - Street 1:590 SOUTH MARINE DRIVE
Practice Address - Street 2:SUITE 131, GITC BLDG
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96931
Practice Address - Country:US
Practice Address - Phone:671-649-0600
Practice Address - Fax:671-649-0666
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUGUAM LIC. 016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU168Medicaid