Individual
DR. EJIRO VIVIAN AGBORO-IDAHOSA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D
Contact information
Practice address
555 SAINT JOSEPHS BLVD, ELMIRA, NY 14901-3223
(607) 737-7002
(607) 737-1529
Mailing address
571 SAINT JOSEPHS BLVD FL 2, ELMIRA, NY 14901-3230
(607) 271-2050
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
275859
NY
2084P0800X
Psychiatry Physician
38473
IA
2084P0804X
Child & Adolescent Psychiatry Physician
Primary
38473
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04061661
—
NY
01
—
1243767
CONTROLLED SUBSTANCE CERTIFICATE
IA
01
—
275859
STATE LICENSE
NY
01
—
38473
IOWA LICENSE
IA
Enumeration date
07/08/2008
Last updated
06/08/2016
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