Provider Demographics
NPI:1255741005
Name:PYO, AUGUSTINE
Entity type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:
Last Name:PYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON ST # 400
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-2401
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE
Practice Address - Street 2:BLDG 11, SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:424-529-6755
Practice Address - Fax:424-338-8984
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139002207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program