Healthcare Provider Details

I. General information

NPI: 1871595488
Provider Name (Legal Business Name): MICHAEL A DAGOSTINO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 1 S
ST AUGUSTINE FL
32084-4211
US

IV. Provider business mailing address

1400 US HIGHWAY 1 S
ST AUGUSTINE FL
32084-4211
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-2286
  • Fax: 904-810-5687
Mailing address:
  • Phone: 904-829-2286
  • Fax: 904-810-5687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3884
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: