Provider Demographics
NPI:1215198007
Name:DAIGRE, JUSTIN L (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:L
Last Name:DAIGRE
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 1:1103 16TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3595
Mailing Address - Country:US
Mailing Address - Phone:256-350-0362
Mailing Address - Fax:256-355-9779
Practice Address - Street 1:1103 16TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3595
Practice Address - Country:US
Practice Address - Phone:256-350-0362
Practice Address - Fax:256-355-9779
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24565207X00000X, 174400000X
ALR9794208600000X
OH35.123634207XX0004X
AL34176207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I708313OtherMEDICARE PTAN
AL172883Medicaid