Agustin V Vitualla, MD
Individual provider Active NPI General Practice Physician · Camden, TN
NPI 1134217029 · NPPES record last updated Oct 20, 2011
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128a(1) exclusion effective Nov 20, 2022.
Key facts
- NPI
- 1134217029
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Physician 208D00000X
- License
- 017177 (TN)
- Practice address
- 135 Hospital Dr
Camden, TN 38320 - Phone
- (731) 584-2117
- Fax
- (731) 584-3564
- NPI assigned
- Oct 10, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- HHS exclusion list flag
- The National Provider Directory flags this NPI as appearing on an HHS exclusion list.
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Behavioral Medicine, PLLC | Past |
Accepting new patients | |
| Thornburg Family Medical Clinic, Inc | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Physician | 208D00000X | 017177 | TN | Yes |
Addresses
Primary practice location
135 Hospital Dr
Camden, TN 38320
Mailing address
PO Box 625
135 Hospital Dr
Camden, TN 38320
Phone (731) 584-2117
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3021196 | Medicaid | TN |
Other providers in Camden, TN
- Leigh Danielle Sturdivant
- Thornburg Family Medical Clinic, Inc
- Kristie Lynn Threet
- Jessica Toombs
- Cristie Anne Vibbert
- Wal-Mart Stores East LP
- Wal-Mart Stores East, LP
- Bobbie Walker
- Janet Warren
- Victoria Watson
All providers in Camden, TN · General Practice Physician in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 20, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- OIG LEIE (HHS Office of Inspector General).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.