Provider Demographics
NPI:1639122302
Name:JUSTESEN, ANTHONY RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:RAY
Last Name:JUSTESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:RAY
Other - Last Name:JUTESEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20805 W 151ST ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7249
Mailing Address - Country:US
Mailing Address - Phone:913-324-8571
Mailing Address - Fax:
Practice Address - Street 1:20805 W 151ST ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7249
Practice Address - Country:US
Practice Address - Phone:913-324-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28962207Q00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100384140AMedicaid
H30184Medicare UPIN
KS033F196DMedicare PIN