Provider Demographics
NPI:1609188432
Name:NEILL, JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:NEILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-2584
Mailing Address - Country:US
Mailing Address - Phone:513-420-5017
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:4750 HEMPSTEAD STATION DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-5164
Practice Address - Country:US
Practice Address - Phone:800-875-0136
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116024153390200000X
OH35-121363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program