Provider Demographics
NPI:1295363612
Name:HALL, JUSTIN ALEXANDER
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALEXANDER
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15405 SE 105TH TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-4637
Mailing Address - Country:US
Mailing Address - Phone:352-789-1503
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BOULEVARD DEPARTMENT OF OTOLARYNGOLOGY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program