Provider Demographics
NPI:1053463141
Name:BISHOP, JUSTIN AVERY (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:AVERY
Last Name:BISHOP
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:PO BOX 64478
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4478
Mailing Address - Country:US
Mailing Address - Phone:410-955-8116
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-2101
Practice Address - Country:US
Practice Address - Phone:410-955-3580
Practice Address - Fax:410-614-7726
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD70023207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD035296900Medicaid
MD183099YWBMedicare PIN