Provider Demographics
NPI:1699775619
Name:AGNONE, LOUIS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:MICHAEL
Last Name:AGNONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4800 BELFORT ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-398-3262
Mailing Address - Fax:904-265-4807
Practice Address - Street 1:3635 S. CLYDE MORRIS BLVD
Practice Address - Street 2:STE 100
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-788-1242
Practice Address - Fax:386-758-8802
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 56146207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270349100Medicaid
FL08476ZMedicare PIN
FLE22497Medicare UPIN