Provider Demographics
NPI:1003479213
Name:COLES, JUSTIN SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SCOTT
Last Name:COLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 HARRISON BLVD STE 700A
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3295
Mailing Address - Country:US
Mailing Address - Phone:801-387-5300
Mailing Address - Fax:801-387-5333
Practice Address - Street 1:4403 HARRISON BLVD STE 700A
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3295
Practice Address - Country:US
Practice Address - Phone:801-387-5300
Practice Address - Fax:801-387-5333
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12094429-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program