Provider Demographics
NPI:1538113790
Name:SCOVILLE, AGNES (MD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:
Last Name:SCOVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AGNES
Other - Middle Name:M
Other - Last Name:STACIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1825 PONCE DE LEON BLVD # 646
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4418
Mailing Address - Country:US
Mailing Address - Phone:323-527-5537
Mailing Address - Fax:
Practice Address - Street 1:6200 SW 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4679
Practice Address - Country:US
Practice Address - Phone:786-662-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1538113790207P00000X
CAA77262207P00000X
FLME165800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A772620Medicaid
CAWA77262EMedicare PIN
H65766Medicare UPIN
CAWA77262FMedicare PIN