Provider Demographics
NPI:1427057801
Name:AGOSTO, MYRNA M (OD)
Entity type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:M
Last Name:AGOSTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:A5 A STREET TOA LINDA
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:787-730-4966
Mailing Address - Fax:787-730-4966
Practice Address - Street 1:CALLE GEORGETTI #128
Practice Address - Street 2:
Practice Address - City:NARANJITO
Practice Address - State:PR
Practice Address - Zip Code:00719-3025
Practice Address - Country:US
Practice Address - Phone:787-869-1911
Practice Address - Fax:787-730-4966
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5-8253Medicare UPIN
PR5-8253Medicare ID - Type Unspecified