Provider Demographics
NPI:1033192604
Name:AGUSTI, JOSE LUIS (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:AGUSTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 E 107TH CT
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2862
Mailing Address - Country:US
Mailing Address - Phone:219-386-5018
Mailing Address - Fax:219-472-0089
Practice Address - Street 1:4900 E 107TH CT
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46307-2862
Practice Address - Country:US
Practice Address - Phone:219-386-5018
Practice Address - Fax:219-472-0089
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061624A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000488177OtherANTHEM
IL036101129 / 05Medicaid
IL01621679OtherBCBS OF IL
IN200832510Medicaid
ILH 34127Medicare UPIN
IN200832510Medicaid