=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699775619
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS MICHAEL AGNONE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2005
-----------------------------------------------------
Last Update Date | 05/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 S. CLYDE MORRIS BLVD STE 100
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-788-1242
-----------------------------------------------------
Fax | 386-758-8802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4800 BELFORT ROAD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-398-3262
-----------------------------------------------------
Fax | 904-265-4807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | ME 56146
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------