Provider Demographics
NPI:1336105618
Name:WASHINGTON, JUSTIN I (RD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:I
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9540 S INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1410
Mailing Address - Country:US
Mailing Address - Phone:312-572-1231
Mailing Address - Fax:312-572-1230
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:PROVIDENT HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-1231
Practice Address - Fax:312-572-1230
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered