Provider Demographics
NPI:1184693236
Name:AUGUSTINE, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
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 1:3671 SOUTHWESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1752
Mailing Address - Country:US
Mailing Address - Phone:716-662-2595
Mailing Address - Fax:
Practice Address - Street 1:3671 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1752
Practice Address - Country:US
Practice Address - Phone:716-662-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101292-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01359017Medicaid
NYB36116Medicare UPIN
NY01359017Medicaid