Provider Demographics
NPI:1619944774
Name:AGUSTIN, AMELIA V (MD)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:V
Last Name:AGUSTIN
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 1:20397 ROUTE 19
Mailing Address - Street 2:TWO LANDMARK NORTH SUITE 220
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066
Mailing Address - Country:US
Mailing Address - Phone:724-772-5430
Mailing Address - Fax:724-772-5431
Practice Address - Street 1:20397 ROUTE 19
Practice Address - Street 2:TWO LANDMARK NORTH SUITE 220
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066
Practice Address - Country:US
Practice Address - Phone:724-772-5430
Practice Address - Fax:724-772-5431
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035077L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000690637006Medicaid
B40021Medicare UPIN