Basic Information
| Provider Information | |||||||||
| NPI: | 1649279373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGRA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7527 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430170727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147885400 | ||||||||
| FaxNumber: | 6147885500 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147885400 | ||||||||
| FaxNumber: | 6147885500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 35-073306 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RA0401X | 35073306 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2072206 | 05 | OH | MEDICAID |