Healthcare Provider Details

I. General information

NPI: 1619919735
Provider Name (Legal Business Name): JOSEPH CHARLES DAGOSTINO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 COFFEE RD MEMORIAL MED CTR
MODESTO CA
95355
US

IV. Provider business mailing address

PO BOX 578255
MODESTO CA
95357-8255
US

V. Phone/Fax

Practice location:
  • Phone: 209-569-7600
  • Fax:
Mailing address:
  • Phone: 209-484-0435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A7531
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number20A7531
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: