Provider Demographics
NPI:1114115821
Name:COLE, JUSTIN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:COLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:201 LE PHILLIP CT NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2900
Mailing Address - Country:US
Mailing Address - Phone:704-782-1127
Mailing Address - Fax:704-782-1207
Practice Address - Street 1:WHITE RIVER JUNCTION VA MEDICAL CENTER DESK 100-112
Practice Address - Street 2:215 N. MAIN STREET
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist