Provider Demographics
NPI:1881630929
Name:AUGUST, ANISSA G (MD)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:G
Last Name:AUGUST
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 203474
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-3474
Mailing Address - Country:US
Mailing Address - Phone:940-626-8044
Mailing Address - Fax:940-626-8055
Practice Address - Street 1:2401 S FM 51
Practice Address - Street 2:SUITE100
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3781
Practice Address - Country:US
Practice Address - Phone:940-626-8044
Practice Address - Fax:940-626-8055
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7651208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046745805Medicaid
TX184194202Medicaid
TX8AB020OtherBCBS