Provider Demographics
NPI:1235227018
Name:AGUSTIN, MARIA LOURDES SAN GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA LOURDES
Middle Name:SAN GABRIEL
Last Name:AGUSTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CLERMONT AVE
Mailing Address - Street 2:APT. 305
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-2309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 WILLOUGHBY ST
Practice Address - Street 2:SUITE NO. 19C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5465
Practice Address - Country:US
Practice Address - Phone:718-250-6925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242033207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine