Provider Demographics
NPI:1508801689
Name:JUSTICE, MARILYN K (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:K
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5408 COLLEYVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5833
Mailing Address - Country:US
Mailing Address - Phone:817-498-9920
Mailing Address - Fax:817-498-0635
Practice Address - Street 1:5408 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5833
Practice Address - Country:US
Practice Address - Phone:817-498-9920
Practice Address - Fax:817-498-0635
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK3596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1175861-05Medicaid
TX080143516OtherRR MEDICARE
TX8D8268Medicare ID - Type Unspecified
TX080143516OtherRR MEDICARE
TX84096NMedicare ID - Type Unspecified