Provider Demographics
NPI:1285946129
Name:AUGUSTON, PRISCILLA (MD)
Entity type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
Last Name:AUGUSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-1147
Mailing Address - Country:US
Mailing Address - Phone:773-483-5011
Mailing Address - Fax:773-483-5594
Practice Address - Street 1:1135 W 69TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1147
Practice Address - Country:US
Practice Address - Phone:773-483-5011
Practice Address - Fax:773-483-5594
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.058681207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine