Provider Demographics
NPI:1720632482
Name:AUGUSTINE, JOB DANIEL (MD)
Entity type:Individual
Prefix:
First Name:JOB
Middle Name:DANIEL
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:DANIEL
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1104 N MISSION RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1017
Mailing Address - Country:US
Mailing Address - Phone:323-343-0569
Mailing Address - Fax:
Practice Address - Street 1:1104 N MISSION RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1017
Practice Address - Country:US
Practice Address - Phone:323-343-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107596207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic PathologyGroup - Single Specialty