Provider Demographics
NPI:1619058377
Name:AUGUSTINE, LORETTA D (MD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:D
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 SW 74TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5165
Mailing Address - Country:US
Mailing Address - Phone:305-665-4614
Mailing Address - Fax:305-667-0239
Practice Address - Street 1:17240 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8921
Practice Address - Country:US
Practice Address - Phone:352-544-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049362207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF20008Medicare UPIN