Provider Demographics
NPI:1235127127
Name:MARTIN, AGUSTIN ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:ALFONSO
Last Name:MARTIN
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:PO BOX 15876
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33684-5876
Mailing Address - Country:US
Mailing Address - Phone:813-849-5437
Mailing Address - Fax:813-849-2624
Practice Address - Street 1:1922 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6510
Practice Address - Country:US
Practice Address - Phone:813-849-5437
Practice Address - Fax:813-849-2624
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56110208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037954900Medicaid
FL037954900Medicaid