Basic Information
| Provider Information | |||||||||
| NPI: | 1760555494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGUSTIN | ||||||||
| FirstName: | MAVICTORIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1090 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295511090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438570111 | ||||||||
| FaxNumber: | 8438570206 | ||||||||
| Practice Location | |||||||||
| Address1: | 545 SUMTER HWY | ||||||||
| Address2: | |||||||||
| City: | BISHOPVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290107601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034845317 | ||||||||
| FaxNumber: | 8034844533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2010-00505 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 410323800 | 05 | MD | MEDICAID | 8902644 | 05 | NC | MEDICAID | 355715 | 05 | SC | MEDICAID | 201000505 | 05 | NC | MEDICAID |