MEDICARE: PATRINA OPAL AGOSTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207VF0040X	Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician	01089837A	IN

General Provider Information

NPI Number	:	1346703782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRINA OPAL AGOSTA MD

Provider Business Mailing Address
First Line	:	550 UNIVERSITY BLVD STE 2301
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5149
Country	:	US
Telephone Number	:	317-948-4103
Fax Number	:	317-948-7454

Provider Business Practice Location Address
First Line	:	550 UNIVERSITY BLVD STE 2301
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5149
Country	:	US
Telephone Number	:	317-948-4103
Fax Number	:	317-948-7454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2019
Last Update Date	:	06/28/2023

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Directions to “ PATRINA OPAL AGOSTA MD” Practice Location

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