Provider Demographics
NPI:1023014966
Name:JUSTICE, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 FAIRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-8144
Mailing Address - Country:US
Mailing Address - Phone:937-492-8431
Mailing Address - Fax:937-498-5126
Practice Address - Street 1:1205 FAIRINGTON DR
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-8144
Practice Address - Country:US
Practice Address - Phone:937-492-8431
Practice Address - Fax:937-498-5126
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2178996Medicaid
OHJU0899831Medicare ID - Type Unspecified
OH2178996Medicaid