Provider Demographics
NPI:1649363755
Name:JOHNSON-AGBAKWU, CRISTA E (MD, MSC)
Entity type:Individual
Prefix:DR
First Name:CRISTA
Middle Name:E
Last Name:JOHNSON-AGBAKWU
Suffix:
Gender:F
Credentials:MD, MSC
Other - Prefix:DR
Other - First Name:CRISTA
Other - Middle Name:E
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MSC
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:33 KENDALL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2726
Practice Address - Country:US
Practice Address - Phone:508-334-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40882207V00000X
MA1013899207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ362751Medicaid
AZZ170337Medicare PIN
AZZ133946Medicare PIN