Provider Demographics
NPI:1477500874
Name:MARK G AGRESTI MD PA
Entity Type:Organization
Organization Name:MARK G AGRESTI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:AGRESTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-842-9550
Mailing Address - Street 1:2010 CONTINENTAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2026
Mailing Address - Country:US
Mailing Address - Phone:561-842-9550
Mailing Address - Fax:561-842-9114
Practice Address - Street 1:2010 CONTINENTAL DRIVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2026
Practice Address - Country:US
Practice Address - Phone:561-842-9550
Practice Address - Fax:561-842-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME604602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3896AMedicare PIN