Provider Demographics
NPI:1760555494
Name:AGUSTIN, MAVICTORIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAVICTORIA
Middle Name:
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:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:843-857-0206
Practice Address - Street 1:545 SUMTER HWY
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-7601
Practice Address - Country:US
Practice Address - Phone:803-484-5317
Practice Address - Fax:803-484-4533
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00505208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410323800Medicaid
NC8902644Medicaid
SC355715Medicaid
NC201000505Medicaid
SC355715Medicaid