Healthcare Provider Details

I. General information

NPI: 1255664769
Provider Name (Legal Business Name): MARK LAWRENCE D'AGOSTINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 MAIN ST
SARASOTA FL
34236-5637
US

IV. Provider business mailing address

5323 SIESTA COVE DR
SARASOTA FL
34242-1702
US

V. Phone/Fax

Practice location:
  • Phone: 203-441-7374
  • Fax:
Mailing address:
  • Phone: 617-785-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number60333
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number270357
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2021-03385
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME144849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: