Provider Demographics
NPI:1164476792
Name:AGOSTINI, MARK ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:AGOSTINI
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 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-8869
Mailing Address - Country:US
Mailing Address - Phone:214-645-8800
Mailing Address - Fax:214-648-6320
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-0624
Practice Address - Fax:214-645-0078
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK48432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104901702Medicaid
G03081Medicare UPIN
TX104901702Medicaid