Provider Demographics
NPI:1275827248
Name:ELLETT, JUSTIN DANIEL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DANIEL
Last Name:ELLETT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
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Mailing Address - Street 1:641 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7165
Mailing Address - Country:US
Mailing Address - Phone:843-766-4070
Mailing Address - Fax:843-766-0633
Practice Address - Street 1:2687 LAKE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-572-1010
Practice Address - Fax:843-569-1719
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC33598208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC335989Medicaid
SC1275827248OtherMEDCOST
SC1275827248OtherMEDCOST