Provider Demographics
NPI:1902917487
Name:AUGUSTIN, WISLY G (MD)
Entity Type:Individual
Prefix:MR
First Name:WISLY
Middle Name:G
Last Name:AUGUSTIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 LIVINGSTON ST STE 3L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5127
Mailing Address - Country:US
Mailing Address - Phone:929-295-6616
Mailing Address - Fax:929-295-6594
Practice Address - Street 1:100 LIVINGSTON ST STE 3L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5127
Practice Address - Country:US
Practice Address - Phone:929-295-6616
Practice Address - Fax:929-295-6594
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY235739-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02839325Medicaid
NYA400010701Medicare PIN
NYA400136647Medicare PIN