Provider Demographics
NPI:1578522918
Name:D'AGOSTINO, RONALD P JR (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:P
Last Name:D'AGOSTINO
Suffix:JR
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 1:108 W EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-1214
Mailing Address - Country:US
Mailing Address - Phone:906-524-6366
Mailing Address - Fax:906-524-6014
Practice Address - Street 1:108 W EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946
Practice Address - Country:US
Practice Address - Phone:906-524-6636
Practice Address - Fax:906-524-6014
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI08281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4137523Medicaid
MIB44268Medicare UPIN
0M82630002Medicare ID - Type Unspecified