MEDICARE: AGUSTIN ALFONSO MARTIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME56110	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235127127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGUSTIN ALFONSO MARTIN MD

Provider Business Mailing Address
First Line	:	PO BOX 15876
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33684-5876
Country	:	US
Telephone Number	:	813-849-5437
Fax Number	:	813-849-2624

Provider Business Practice Location Address
First Line	:	1922 W DR MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6510
Country	:	US
Telephone Number	:	813-849-5437
Fax Number	:	813-849-2624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	04/01/2014

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