Provider Demographics
NPI:1093742439
Name:AGOSTA, ANDREW M (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:AGOSTA
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 1:51221 SCHOENHERR, SUITE 201
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315
Mailing Address - Country:US
Mailing Address - Phone:586-254-3545
Mailing Address - Fax:586-254-3136
Practice Address - Street 1:51221 SCHOENHERR, SUITE 201
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-254-3545
Practice Address - Fax:586-254-3136
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI049469207V00000X
MI046469208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2931963Medicaid
MID74258Medicare UPIN
MI0E06281009Medicare ID - Type Unspecified