Provider Demographics
NPI:1558468561
Name:AGUSTIN, CONRADO M SR (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRADO
Middle Name:M
Last Name:AGUSTIN
Suffix:SR
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 1:6905 E STONEGATE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1135
Mailing Address - Country:US
Mailing Address - Phone:316-681-3409
Mailing Address - Fax:
Practice Address - Street 1:2707 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2249
Practice Address - Country:US
Practice Address - Phone:316-691-0249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-15625207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100081020AMedicaid
KS645010OtherFIRSTGUARD PROVIDER NUMBE
KS100321990DMedicaid
KS100081020AMedicaid
KS100321990DMedicaid