Provider Demographics
NPI:1477754638
Name:AGUSTA, VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:AGUSTA
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 1:555 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2250
Mailing Address - Country:US
Mailing Address - Phone:717-544-5511
Mailing Address - Fax:
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA002115208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA20051635OtherMERCY
PA0038027000OtherINDEPENDENCE BLUE CROSS
PA20051635OtherMERCY