Provider Demographics
NPI:1437805512
Name:DAVIS, JUSTEIN
Entity Type:Individual
Prefix:
First Name:JUSTEIN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 LINCOLN AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-2653
Mailing Address - Country:US
Mailing Address - Phone:973-570-7140
Mailing Address - Fax:
Practice Address - Street 1:32 LINCOLN AVE APT 313
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-2653
Practice Address - Country:US
Practice Address - Phone:973-570-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-27
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver