Provider Demographics
NPI:1528100088
Name:JOSEPH R AGOSTINELLI DPM PA
Entity type:Organization
Organization Name:JOSEPH R AGOSTINELLI DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:AGOSTINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-863-2153
Mailing Address - Street 1:1034 MAR WALT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:850-315-9350
Practice Address - Street 1:1034 MAR WALT DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:850-315-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002643213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65837OtherBS PROVIDER NUMBER
FL340506100Medicaid
FL65837OtherBS PROVIDER NUMBER
FLU3404ZMedicare ID - Type UnspecifiedMEDICARE PPIN
FL5232980003Medicare NSC
FLK6400Medicare PIN
FLV01504Medicare UPIN
FL340506100Medicaid