Provider Demographics
NPI:1245209881
Name:JUSTICE, JASON ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:JUSTICE
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 1:2240 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4725
Mailing Address - Country:US
Mailing Address - Phone:704-671-5344
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2240 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4725
Practice Address - Country:US
Practice Address - Phone:704-671-5344
Practice Address - Fax:704-671-5331
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301480207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903752Medicaid
SCN0148AMedicaid
NC5903752Medicaid
SCN0148AMedicaid