Provider Demographics
NPI:1073749222
Name:DESTYONCALL PEDIATRICS
Entity Type:Organization
Organization Name:DESTYONCALL PEDIATRICS
Other - Org Name:DESTYONCALL HEALTHCARE
Other - Org Type:Other Name
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-627-6101
Mailing Address - Street 1:321 YALE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1247
Mailing Address - Country:US
Mailing Address - Phone:856-627-6101
Mailing Address - Fax:856-627-6103
Practice Address - Street 1:321 YALE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1247
Practice Address - Country:US
Practice Address - Phone:856-627-6101
Practice Address - Fax:856-627-6103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0063002Medicaid