Provider Demographics
NPI:1841241577
Name:DEAUGUSTINE, CARLO J (DO)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:J
Last Name:DEAUGUSTINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S FRONT ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-782-5908
Practice Address - Fax:717-782-5716
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004246L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000805010Medicaid
PA000805010Medicaid
PA119602Medicare PIN
PAP00013552Medicare PIN
PA141222OtherUNISON
PA30024896OtherKEYSTONE
PA0008050100007Medicaid
PA119602RQJMedicare PIN
PA50010070OtherCAPITAL BC
PAP00013552Medicare PIN
PA37166OtherGEISINGER