MEDICARE: JONATHAN AGOSTO AUD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	41YA00106700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41YA00106700	OTHER	NJ	STATE OF NJ

General Provider Information

NPI Number	:	1518518851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN AGOSTO AUD

Provider Business Mailing Address
First Line	:	36 NEWARK AVE STE 130
Second Line	:
City	:	BELLEVILLE
State	:	NJ
Zip	:	07109-4120
Country	:	US
Telephone Number	:	973-528-2690
Fax Number	:	973-302-4074

Provider Business Practice Location Address
First Line	:	36 NEWARK AVE STE 130
Second Line	:
City	:	BELLEVILLE
State	:	NJ
Zip	:	07109-4120
Country	:	US
Telephone Number	:	973-528-2690
Fax Number	:	973-302-4074

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	09/27/2019

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