Provider Demographics
NPI:1558610147
Name:LIZAMA, AGUSTIN
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:
Last Name:LIZAMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2677 MOSS AVE #7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065
Mailing Address - Country:US
Mailing Address - Phone:323-526-1254
Mailing Address - Fax:
Practice Address - Street 1:130 W. BRUNO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012
Practice Address - Country:US
Practice Address - Phone:323-526-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator