Provider Demographics
NPI:1760592687
Name:AGOSTO, MARIELY (MD)
Entity Type:Individual
Prefix:
First Name:MARIELY
Middle Name:
Last Name:AGOSTO
Suffix:
Gender:F
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:HM23 CALLE RAMON MORLA
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-3747
Mailing Address - Country:US
Mailing Address - Phone:787-261-3465
Mailing Address - Fax:787-261-3415
Practice Address - Street 1:HE10 AVENUE AMALIA PAOLI
Practice Address - Street 2:
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-261-3465
Practice Address - Fax:787-261-3415
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR12203208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics