Healthcare Provider Details

I. General information

NPI: 1427057801
Provider Name (Legal Business Name): MYRNA M AGOSTO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 12/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE GEORGETTI #128
NARANJITO PR
00719-3025
US

IV. Provider business mailing address

A5 A STREET TOA LINDA
TOA ALTA PR
00953
US

V. Phone/Fax

Practice location:
  • Phone: 787-869-1911
  • Fax: 787-730-4966
Mailing address:
  • Phone: 787-730-4966
  • Fax: 787-730-4966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number312
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: