Provider Demographics
NPI:1063818292
Name:AUGUSTINE ADIBOSHI MD PA
Entity Type:Organization
Organization Name:AUGUSTINE ADIBOSHI MD PA
Other - Org Name:PDJ MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADIBOSHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-432-8831
Mailing Address - Street 1:1824 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3604
Mailing Address - Country:US
Mailing Address - Phone:954-432-8831
Mailing Address - Fax:954-432-8832
Practice Address - Street 1:1824 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3604
Practice Address - Country:US
Practice Address - Phone:954-432-8831
Practice Address - Fax:954-432-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1130972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty