Provider Demographics
NPI:1346323110
Name:AGOSTO, JOSE ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALBERTO
Last Name:AGOSTO
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 1:310 SOUTH EXTENSION ROAD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210
Mailing Address - Country:US
Mailing Address - Phone:480-834-2912
Mailing Address - Fax:480-834-3536
Practice Address - Street 1:310 SOUTH EXTENSION ROAD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210
Practice Address - Country:US
Practice Address - Phone:480-834-2912
Practice Address - Fax:480-834-3536
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ326942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881674Medicaid
AZ102415Medicare ID - Type Unspecified
AZ881674Medicaid