Provider Demographics
NPI:1336263466
Name:NORMAN B SAN AGUSTIN MD PA
Entity Type:Organization
Organization Name:NORMAN B SAN AGUSTIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SAN AGUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-267-2838
Mailing Address - Street 1:344 SOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960
Mailing Address - Country:US
Mailing Address - Phone:973-267-2838
Mailing Address - Fax:973-267-7909
Practice Address - Street 1:344 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960
Practice Address - Country:US
Practice Address - Phone:973-267-2838
Practice Address - Fax:973-267-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03333000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2923602Medicaid
087078Medicare ID - Type Unspecified
NJ2923602Medicaid