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General NPI Number Information
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NPI Number | 1760555494
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Entity Type | Individual
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Provider Name | MAVICTORIA AGUSTIN MD
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Gender | Female
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 10/27/2014
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Provider Practice Location Address
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Address Line | 545 SUMTER HWY
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City | BISHOPVILLE
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State | SC
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Zip | 29010-7601
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Country | US
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Telephone | 803-484-5317
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Fax | 803-484-4533
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Provider Business Mailing Address
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Address Line | PO BOX 1090
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City | HARTSVILLE
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State | SC
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Zip | 29551-1090
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Country | US
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Telephone | 843-857-0111
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Fax | 843-857-0206
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2010-00505
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License Number State | NC
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