Provider Demographics
NPI:1538343561
Name:AUGUSTINE, JEFFREY M (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 CARNEGIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2627
Mailing Address - Country:US
Mailing Address - Phone:216-621-6132
Mailing Address - Fax:
Practice Address - Street 1:6960 SOUTH EDGERTON ROAD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141
Practice Address - Country:US
Practice Address - Phone:440-740-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4170T24152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0865710Medicaid
OH0865710Medicaid