Provider Demographics
NPI:1760576623
Name:ENEIDA AGOSTO, MD PC
Entity Type:Organization
Organization Name:ENEIDA AGOSTO, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ENEIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGOSTO-COLON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-507-5400
Mailing Address - Street 1:3755 72ND ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6144
Mailing Address - Country:US
Mailing Address - Phone:718-507-5400
Mailing Address - Fax:718-507-5422
Practice Address - Street 1:3755 72ND ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6144
Practice Address - Country:US
Practice Address - Phone:718-507-5400
Practice Address - Fax:718-507-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211512207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG100051814Medicare PIN