Provider Demographics
NPI:1346428810
Name:FOXWORTH, JUSTIN ADRIAN (IDC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ADRIAN
Last Name:FOXWORTH
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1683 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23511-2731
Mailing Address - Country:US
Mailing Address - Phone:757-445-5310
Mailing Address - Fax:
Practice Address - Street 1:1683 GILBERT ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2731
Practice Address - Country:US
Practice Address - Phone:757-445-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman