Provider Demographics
NPI:1740423417
Name:AGBAOSI, TINA A (MD)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:A
Last Name:AGBAOSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:323-467-7119
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-545-6969
Practice Address - Fax:901-545-6424
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47524207RI0200X
OH57.015230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525608Medicaid
TN103I115728OtherMEDICARE TN