Provider Demographics
NPI:1144287087
Name:AGENS, JOHN ELLIS JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ELLIS
Last Name:AGENS
Suffix:JR
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 3064300
Mailing Address - Street 2:1115 WEST CALL STREET, SUITE 1121-C
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32306-4300
Mailing Address - Country:US
Mailing Address - Phone:850-645-9350
Mailing Address - Fax:850-645-0577
Practice Address - Street 1:4449 MEANDERING WAY
Practice Address - Street 2:FSU SENIORHEALTH AT WOK
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5740
Practice Address - Country:US
Practice Address - Phone:850-644-1543
Practice Address - Fax:850-645-0577
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 87099207R00000X
FLME87099207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0314ZMedicare Oscar/Certification
FLU0134YMedicare Oscar/Certification
E13102Medicare UPIN