Provider Demographics
NPI:1528217395
Name:MADSON, JUSTIN GERHARD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:GERHARD
Last Name:MADSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 FARNAM ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2806
Mailing Address - Country:US
Mailing Address - Phone:402-552-2555
Mailing Address - Fax:402-552-2573
Practice Address - Street 1:4242 FARNAM ST.
Practice Address - Street 2:SUITE 360
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2850
Practice Address - Country:US
Practice Address - Phone:402-552-2555
Practice Address - Fax:402-552-2598
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27129207N00000X
NE26614207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK403917OtherMEDICARE INDIVIDUAL PTAN