1134166713 NPI number — DR. HEATHER M AUGUSTIN-GAUDIOSO OD

Table of content: DR. HEATHER M AUGUSTIN-GAUDIOSO OD (NPI 1134166713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134166713 NPI number — DR. HEATHER M AUGUSTIN-GAUDIOSO OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUGUSTIN-GAUDIOSO
Provider First Name:
HEATHER
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAUDIOSO
Provider Other First Name:
HEATHER
Provider Other Middle Name:
AUGUSTIN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1134166713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9001 UNBRIDLE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAXHAW
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28173-6774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-974-0750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 LANCASTER BYP W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29720-4773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-357-7700
Provider Business Practice Location Address Fax Number:
803-227-8996
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TUV006911 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2099 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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