Healthcare Provider Details

I. General information

NPI: 1124314760
Provider Name (Legal Business Name): AGOSTO ALLERGY AND IMMUNOLOGY CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 AVE JOSE DE DIEGO E ESQUINA CARRION MADURO
CAYEY PR
00736-3822
US

IV. Provider business mailing address

75 CALLE EUSEBIO ITURRINO
CANOVANAS PR
00729-3221
US

V. Phone/Fax

Practice location:
  • Phone: 787-635-4374
  • Fax: 787-635-4374
Mailing address:
  • Phone: 787-635-4374
  • Fax: 787-905-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number15888
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15888
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME93943
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15888
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME93943
License Number StateFL

VIII. Authorized Official

Name: DR. ANARDI AGOSTO-MUJICA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-403-3611