Provider Demographics
NPI:1669491296
Name:HART, JUSTIN LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:HART
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W LOYAL LN
Mailing Address - Street 2:
Mailing Address - City:CLEVER
Mailing Address - State:MO
Mailing Address - Zip Code:65631-9113
Mailing Address - Country:US
Mailing Address - Phone:417-583-2138
Mailing Address - Fax:
Practice Address - Street 1:612 E ELM ST
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1552
Practice Address - Country:US
Practice Address - Phone:417-732-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2116002Medicare PIN