Provider Demographics
NPI:1093796450
Name:AUGUSTINE, MUDDAMALLE J (MD)
Entity Type:Individual
Prefix:
First Name:MUDDAMALLE
Middle Name:J
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BRENDA LN
Mailing Address - Street 2:SUITE E
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-3783
Mailing Address - Country:US
Mailing Address - Phone:817-545-7474
Mailing Address - Fax:
Practice Address - Street 1:912 WRIGHT ST
Practice Address - Street 2:SUITE E
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4759
Practice Address - Country:US
Practice Address - Phone:817-861-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD34183Medicare UPIN