Provider Demographics
NPI:1326210857
Name:DOUGLAS, JUSTIN WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WAYNE
Last Name:DOUGLAS
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 1:206 SKYLAR DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9383
Mailing Address - Country:US
Mailing Address - Phone:681-318-3540
Mailing Address - Fax:
Practice Address - Street 1:1256 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3120
Practice Address - Country:US
Practice Address - Phone:304-254-2641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101263258207Y00000X
KY55925207Y00000X
WV23770207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV23770OtherWV MEDICAL LICENSE
VA0101263258OtherVA MEDICAL LICENSE