Basic Information
| Provider Information | |||||||||
| NPI: | 1831345123 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGUSTIN | ||||||||
| FirstName: | TERENCE LOU | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 MARKS STREET | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026711000 | ||||||||
| FaxNumber: | 7024580610 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 MARKS STREET | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026711000 | ||||||||
| FaxNumber: | 7024580610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 14777 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1831345123 | 05 | NV | MEDICAID |