Ejiro Vivian Agboro-Idahosa, M.D

Primary specialty

Child & Adolescent Psychiatry PhysicianTaxonomy code 2084P0804X

License

38473 Issued in IA

Practice address

555 Saint Josephs Blvd
Elmira, NY 14901-3223

Phone

(607) 737-7002

Fax

(607) 737-1529

NPI assigned

Jul 8, 2008

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 4

Other names 1

• Dr. Ejiro Vivian Agboro Former name

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Psychiatry

Education

Other, 1994

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Waverly Medical Associates LLCGroup PAC ID 0547589541, 2 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Waverly Medical Associates LLC

  • Internal Medicine Physician
  • Waverly, NY
  • NPI 1457757486

  Psychiatry

  Medicare reassignment Care Compare group NPD
• Ven Mental Health and TMS Clinic LLC

  • Psychiatry Physician
  • Dakota Dunes, SD
  • NPI 1467341628
  NPD
• Arnot Ogden Medical Center

  • General Acute Care Hospital
  • Elmira, NY
  • NPI 1083605661
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1215475200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1465344000000",
    "number": "1104089390",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "571 SAINT JOSEPHS BLVD FL 2",
            "city": "ELMIRA",
            "state": "NY",
            "postal_code": "149013230",
            "telephone_number": "607-271-2050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "555 SAINT JOSEPHS BLVD",
            "city": "ELMIRA",
            "state": "NY",
            "postal_code": "149013223",
            "telephone_number": "607-737-7002",
            "fax_number": "607-737-1529"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "AGBORO-IDAHOSA",
        "first_name": "EJIRO",
        "middle_name": "VIVIAN",
        "name_prefix": "Dr.",
        "credential": "M.D",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2008-07-08",
        "last_updated": "2016-06-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "IA",
            "license": "38473",
            "primary": false
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "IA",
            "license": "38473",
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NY",
            "license": "275859",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "IOWA LICENSE",
            "identifier": "38473",
            "state": "IA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "275859",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CONTROLLED SUBSTANCE CERTIFICATE",
            "identifier": "1243767",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "04061661",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "EJIRO",
            "last_name": "AGBORO",
            "middle_name": "VIVIAN",
            "prefix": "DR.",
            "credential": "M.D",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Snigdha Adusumalli, MBBS
• Advantagehealth Medical Services, PC
• Affiliated Psychological Consultants PC
• Sameea Aftab, MD
• Hafsa Afzaal
• Khizran Agha, MD
• Francis Badu Agyemang, MD
• Sarfaraz Ahmad
• Inam Shafiq Ahmed, MD
• Madiha Akhter

• Child & Adolescent Psychiatry Physician in Elmira, NY
• Providers in Elmira, NY by specialty
• Child & Adolescent Psychiatry Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 8, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.