Provider Demographics
NPI:1154510758
Name:AGOSTINELLI, JOHN ARTHUR SR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ARTHUR
Last Name:AGOSTINELLI
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 NW 131ST AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-2217
Mailing Address - Country:US
Mailing Address - Phone:954-452-0460
Mailing Address - Fax:
Practice Address - Street 1:461 NW 131ST AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33325-2217
Practice Address - Country:US
Practice Address - Phone:954-452-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0001889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD27352Medicare UPIN