Provider Demographics
NPI:1609557313
Name:KOREN, JUSTIN GREGORY (SO-ATP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GREGORY
Last Name:KOREN
Suffix:
Gender:M
Credentials:SO-ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MARDIV
Mailing Address - Street 2:2D RECONNAISSANCE BN, CAMP LEJEUNE
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:28542-0138
Mailing Address - Country:US
Mailing Address - Phone:910-440-7703
Mailing Address - Fax:
Practice Address - Street 1:2D MARDIV
Practice Address - Street 2:2D RECONNAISSANCE BN
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-440-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman