Provider Demographics
NPI:1053511295
Name:JUSTICE, HEATHER M (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:JUSTICE
Suffix:
Gender:F
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 661448
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1448
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-623-1227
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-403-1050
Practice Address - Fax:626-623-1227
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29891207PE0004X
WAMD60170287207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031508Medicaid
SC298911Medicaid