Provider Demographics
NPI:1891764122
Name:DAVILA AGOSTO, LYSBETH R (DPM)
Entity type:Individual
Prefix:
First Name:LYSBETH
Middle Name:R
Last Name:DAVILA AGOSTO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 AVE DOMENECH
Mailing Address - Street 2:STE 508
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3705
Mailing Address - Country:US
Mailing Address - Phone:787-274-1843
Mailing Address - Fax:787-274-1843
Practice Address - Street 1:400 AVE DOMENECH
Practice Address - Street 2:STE 508
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3705
Practice Address - Country:US
Practice Address - Phone:787-274-1843
Practice Address - Fax:787-274-1843
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2016-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR80213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0048095Medicare ID - Type UnspecifiedPUERTO RICO