Provider Demographics
NPI:1144230749
Name:DAGOSTINO, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DAGOSTINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-776-1288
Mailing Address - Fax:203-776-7741
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-776-1288
Practice Address - Fax:203-776-7741
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT034314207Y00000X, 207YP0228X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT040011092OtherRAILROAD MEDICARE PIN
CT001343144Medicaid
G41465Medicare UPIN
CT040000294Medicare ID - Type Unspecified