Provider Demographics
NPI:1952596173
Name:AGOSTINI, RON A (PT)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:A
Last Name:AGOSTINI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 GOLD STAR HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6702
Mailing Address - Country:US
Mailing Address - Phone:860-445-9433
Mailing Address - Fax:860-445-8802
Practice Address - Street 1:481 GOLD STAR HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6702
Practice Address - Country:US
Practice Address - Phone:860-445-9433
Practice Address - Fax:860-445-8802
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001173Medicare PIN