Provider Demographics
NPI:1114123122
Name:AUGUSTINE, ROSE C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:C
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3012
Mailing Address - Country:US
Mailing Address - Phone:706-279-1994
Mailing Address - Fax:706-279-9229
Practice Address - Street 1:1610 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3012
Practice Address - Country:US
Practice Address - Phone:706-279-1994
Practice Address - Fax:706-279-9229
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062465208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics