Healthcare Provider Details

I. General information

NPI: 1003864315
Provider Name (Legal Business Name): MARILOU LEJANO SAN AGUSTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
CHATTAHOOCHEE FL
32324-1107
US

IV. Provider business mailing address

100 N MAIN ST
CHATTAHOOCHEE FL
32324-1107
US

V. Phone/Fax

Practice location:
  • Phone: 850-663-7807
  • Fax:
Mailing address:
  • Phone: 850-663-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME46640
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: