Provider Demographics
NPI:1437419801
Name:JUSTICE, JOHNATHON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNATHON
Middle Name:DAVID
Last Name:JUSTICE
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 1:704 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:THORP
Mailing Address - State:WI
Mailing Address - Zip Code:54771-7624
Mailing Address - Country:US
Mailing Address - Phone:715-669-7279
Mailing Address - Fax:
Practice Address - Street 1:704 S CLARK ST
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-7624
Practice Address - Country:US
Practice Address - Phone:715-669-7279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-20
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI64039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI64039OtherWI STATE LIC