Provider Demographics
NPI:1841206018
Name:CERVONE, AGOSTINO (MD)
Entity Type:Individual
Prefix:
First Name:AGOSTINO
Middle Name:
Last Name:CERVONE
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 1:185 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2121
Mailing Address - Country:US
Mailing Address - Phone:631-298-4479
Mailing Address - Fax:631-591-3047
Practice Address - Street 1:34 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3118
Practice Address - Country:US
Practice Address - Phone:631-284-9250
Practice Address - Fax:631-284-9249
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214964208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG99268Medicare UPIN