Provider Demographics
NPI:1487663191
Name:POWELL, JUSTIN W (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:W
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:HALLETTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77964-0801
Mailing Address - Country:US
Mailing Address - Phone:361-798-2112
Mailing Address - Fax:361-798-2112
Practice Address - Street 1:147 COUNTY ROAD 129
Practice Address - Street 2:
Practice Address - City:HALLETTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77964-5186
Practice Address - Country:US
Practice Address - Phone:361-798-2112
Practice Address - Fax:361-798-2112
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTXBJ8722207Q00000X, 207R00000X, 208000000X
TXJ8722207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111956205Medicaid
TX111956205Medicaid
TX8A01388Medicare ID - Type Unspecified