Provider Demographics
NPI:1720001613
Name:JAMORA, AUGUSTO M (MD)
Entity Type:Individual
Prefix:DR
First Name:AUGUSTO
Middle Name:M
Last Name:JAMORA
Suffix:
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 1:22250 PROVIDENCE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-552-0360
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 207
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-552-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43-01-0335072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0637767OtherBLUE CROSS BLUE SHIELD
MI43-01-033507OtherPHYSICIAN STATE LICENSE
MIB46251Medicare UPIN
MI0637767OtherBLUE CROSS BLUE SHIELD