Provider Demographics
NPI:1184982134
Name:AUGUSTIN-COLEY, BROOKE (MD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:AUGUSTIN-COLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:AUGUSTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2608 DANFORTH LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2213
Mailing Address - Country:US
Mailing Address - Phone:651-238-6659
Mailing Address - Fax:
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.34125207P00000X
390200000X
GA76290207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty