Provider Demographics
NPI:1164458352
Name:AGOSTINO, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:AGOSTINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9002 NORTH MERIDIAN STREET
Mailing Address - Street 2:SUITE 222
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5350
Mailing Address - Country:US
Mailing Address - Phone:317-844-7059
Mailing Address - Fax:317-819-0044
Practice Address - Street 1:18051 RIVER ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7093
Practice Address - Country:US
Practice Address - Phone:317-844-7059
Practice Address - Fax:317-819-0044
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01038563207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01038563OtherLICENSE
IN000000085510OtherANTHEM PIN
IN100361740AMedicaid
IN100361740AMedicaid
IN739280EMedicare PIN
IN000000085510OtherANTHEM PIN