Provider Demographics
NPI:1932103397
Name:AGOSTINELLI, JOSEPH R (DPM PA)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:AGOSTINELLI
Suffix:
Gender:M
Credentials:DPM PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 MAR WALT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:850-315-9350
Practice Address - Street 1:1034 MAR WALT DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:850-315-9350
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2643213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340506100Medicaid
FLK6400Medicare ID - Type UnspecifiedMEDICARE GROUP #
FL5232980002Medicare NSC
FL340506100Medicaid
FL5232980001Medicare NSC
FLU3404ZMedicare ID - Type UnspecifiedMEDICARE PPIN
FL5232980003Medicare NSC