Healthcare Provider Details

I. General information

NPI: 1891764122
Provider Name (Legal Business Name): LYSBETH R DAVILA AGOSTO DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 05/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE DOMENECH STE 508
SAN JUAN PR
00918-3705
US

IV. Provider business mailing address

400 AVE DOMENECH STE 508
SAN JUAN PR
00918-3705
US

V. Phone/Fax

Practice location:
  • Phone: 787-274-1843
  • Fax: 787-274-1843
Mailing address:
  • Phone: 787-274-1843
  • Fax: 787-274-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number80
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: