Provider Demographics
NPI:1063867513
Name:LA, JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:LA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:99 MONTECILLO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3308
Mailing Address - Country:US
Mailing Address - Phone:415-444-2919
Mailing Address - Fax:415-444-2328
Practice Address - Street 1:99 MONTECILLO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3308
Practice Address - Country:US
Practice Address - Phone:415-444-2919
Practice Address - Fax:415-444-2328
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2022-08-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA152841208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology