Provider Demographics
NPI:1881628436
Name:AUGUSTIN, GERDA (MD)
Entity type:Individual
Prefix:
First Name:GERDA
Middle Name:
Last Name:AUGUSTIN
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 1:108 W PIKE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2721
Mailing Address - Country:US
Mailing Address - Phone:304-918-9286
Mailing Address - Fax:304-918-9287
Practice Address - Street 1:108 W PIKE ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2721
Practice Address - Country:US
Practice Address - Phone:304-918-9286
Practice Address - Fax:304-918-9287
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07823800208000000X
PAMD427933208D00000X
WV30878208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0063002Medicaid
I42149Medicare UPIN
NJ094796Medicare ID - Type Unspecified