Provider Demographics
NPI:1306849161
Name:POORE, JUSTIN M (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:M
Last Name:POORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 QUAIL RD
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:KS
Mailing Address - Zip Code:66901-6885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 HIGHLAND DR
Practice Address - Street 2:FL 3
Practice Address - City:CONCORDIA
Practice Address - State:KS
Practice Address - Zip Code:66901-3923
Practice Address - Country:US
Practice Address - Phone:785-243-4272
Practice Address - Fax:785-243-4275
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0529357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100415450BMedicaid
KSH49111Medicare UPIN
KS100415450BMedicaid