Provider Demographics
NPI:1518996958
Name:PLAXICO, JUSTIN B (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:B
Last Name:PLAXICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:435 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4676
Mailing Address - Country:US
Mailing Address - Phone:580-310-0102
Mailing Address - Fax:580-310-0104
Practice Address - Street 1:435 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4676
Practice Address - Country:US
Practice Address - Phone:580-310-0102
Practice Address - Fax:580-310-0104
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK3875208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100845690AMedicaid
OK100845690AMedicaid
OKH73425Medicare UPIN