Healthcare Provider Details

I. General information

NPI: 1295986057
Provider Name (Legal Business Name): TIMOTHY JOSEPH D'AGOSTINO SR. RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIMOTHY JOSEPH D'AGOSTINO SR. RPA

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S WOODS MILL RD
CHESTERFIELD MO
63017-3417
US

IV. Provider business mailing address

232 S WOODS MILL RD
CHESTERFIELD MO
63017-3417
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-6314
  • Fax:
Mailing address:
  • Phone: 314-205-6314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number06 MO 1188
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: