Provider Demographics
NPI:1760425987
Name:TIAMSON-KASSAB, MARIA LOURDES AGUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA LOURDES
Middle Name:AGUSTIN
Last Name:TIAMSON-KASSAB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIA LOURDES
Other - Middle Name:AGUSTIN
Other - Last Name:TIAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3350 LA JOLLA VILLAGE DR
Mailing Address - Street 2:VA SAN DIEGO HEALTHCARE SYSTEM
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0002
Mailing Address - Country:US
Mailing Address - Phone:858-552-8585
Mailing Address - Fax:858-642-6442
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:VA SAN DIEGO HEALTHCARE SYSTEM
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:858-642-6442
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1882662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01345284Medicaid
NYF28603Medicare UPIN
NY62K701Medicare ID - Type Unspecified