Provider Demographics
NPI:1528397791
Name:WAYNE P JUSTICE M D P A
Entity Type:Organization
Organization Name:WAYNE P JUSTICE M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-678-0443
Mailing Address - Street 1:1003 COLLEGE BLVD W STE 2
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1069
Mailing Address - Country:US
Mailing Address - Phone:850-678-0443
Mailing Address - Fax:850-678-7999
Practice Address - Street 1:1003 COLLEGE BLVD W STE 2
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1069
Practice Address - Country:US
Practice Address - Phone:850-678-0443
Practice Address - Fax:850-678-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH52569Medicare UPIN