Provider Demographics
NPI:1407892144
Name:AGUSTIN, ERIE T (MD)
Entity type:Individual
Prefix:
First Name:ERIE
Middle Name:T
Last Name:AGUSTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 WOODSIDE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3415
Mailing Address - Country:US
Mailing Address - Phone:718-205-0030
Mailing Address - Fax:718-205-6136
Practice Address - Street 1:5718 WOODSIDE AVE FL 2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3415
Practice Address - Country:US
Practice Address - Phone:718-205-0030
Practice Address - Fax:718-205-6136
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196473207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01551775Medicaid
F91591Medicare UPIN
NY0076RMMedicare PIN
110231450Medicare PIN
NY01551775Medicaid