Provider Demographics
NPI:1205034865
Name:MANS, JUSTIN THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:THOMAS
Last Name:MANS
Suffix:
Gender:M
Credentials:OD
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 277
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-0010
Mailing Address - Country:US
Mailing Address - Phone:541-997-3331
Mailing Address - Fax:
Practice Address - Street 1:535 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439
Practice Address - Country:US
Practice Address - Phone:541-997-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3223ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139325OtherPTAN
OR006330Medicaid
ORR0000WCYBXOtherGROUP PTAN