Provider Demographics
NPI:1962883587
Name:ADDISON, AUGUSTINA
Entity type:Individual
Prefix:
First Name:AUGUSTINA
Middle Name:
Last Name:ADDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:3130 N COUNTY ROAD 25A STE 205
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-335-1660
Practice Address - Fax:937-440-4020
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT209133207V00000X
OH35.140195207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413049Medicaid