Healthcare Provider Details

I. General information

NPI: 1770365090
Provider Name (Legal Business Name): PATRICK JERALD D'AGOSTINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 LOGAN AVE
SAN DIEGO CA
92113-2411
US

IV. Provider business mailing address

2865 LOGAN AVE
SAN DIEGO CA
92113-2411
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-4357
  • Fax: 619-232-7048
Mailing address:
  • Phone: 619-232-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: