Provider Demographics
NPI:1427219948
Name:AGUSTSSON, THOR (DO)
Entity Type:Individual
Prefix:
First Name:THOR
Middle Name:
Last Name:AGUSTSSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03064-2716
Practice Address - Country:US
Practice Address - Phone:603-883-0005
Practice Address - Fax:603-883-0007
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1304932084P0800X
FLOS 120782084P0800X
MEDO24502084P0800X
NH172922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2234315OtherBCBS
IL2234315OtherBCBS