Provider Demographics
NPI:1841231875
Name:AUGUSTINE, VIRUPPAMATTAM M (MD)
Entity Type:Individual
Prefix:
First Name:VIRUPPAMATTAM
Middle Name:M
Last Name:AUGUSTINE
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 1:160 MIDDLE ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782
Mailing Address - Country:US
Mailing Address - Phone:631-589-5533
Mailing Address - Fax:631-589-1501
Practice Address - Street 1:160 MIDDLE ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782
Practice Address - Country:US
Practice Address - Phone:631-589-5533
Practice Address - Fax:631-589-1501
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY129681208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00486071Medicaid
B13349Medicare UPIN