Provider Demographics
NPI:1124314760
Name:AGOSTO ALLERGY AND IMMUNOLOGY CSP
Entity type:Organization
Organization Name:AGOSTO ALLERGY AND IMMUNOLOGY CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANARDI
Authorized Official - Middle Name:
Authorized Official - Last Name:AGOSTO-MUJICA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-403-3611
Mailing Address - Street 1:75 CALLE EUSEBIO ITURRINO
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-3221
Mailing Address - Country:US
Mailing Address - Phone:787-635-4374
Mailing Address - Fax:787-905-7908
Practice Address - Street 1:109 AVE JOSE DE DIEGO E
Practice Address - Street 2:ESQUINA CARRION MADURO
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-3822
Practice Address - Country:US
Practice Address - Phone:787-635-4374
Practice Address - Fax:787-635-4374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15888207R00000X, 208000000X, 207K00000X
FLME93943207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273367600Medicaid
28690OtherBLUE CROSS BLUE SHIELD
PR1215901426Medicare PIN