Provider Demographics
NPI:1073552642
Name:PODESTA, AUGUSTO H (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:H
Last Name:PODESTA
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:PO BOX 60100
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0100
Mailing Address - Country:US
Mailing Address - Phone:203-656-1124
Mailing Address - Fax:
Practice Address - Street 1:30 SHELBURNE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3628
Practice Address - Country:US
Practice Address - Phone:203-276-7424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT27991207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001279919Medicaid
CT001279919Medicaid
P00426616Medicare PIN
CT220000668Medicare PIN