Provider Demographics
NPI:1558454686
Name:AGUSTIN, CONRADO M JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRADO
Middle Name:M
Last Name:AGUSTIN
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:2318 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4436
Mailing Address - Country:US
Mailing Address - Phone:316-262-2415
Mailing Address - Fax:316-262-0318
Practice Address - Street 1:527 N GROVE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4520
Practice Address - Country:US
Practice Address - Phone:316-262-2415
Practice Address - Fax:316-264-4734
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-01-18
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Provider Licenses
StateLicense IDTaxonomies
KS04-30665208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004493060004Medicaid
KS200261450-AMedicaid