Provider Demographics
NPI:1669677928
Name:WEATHERALL, JUSTIN MADISON (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MADISON
Last Name:WEATHERALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3313 W HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-9423
Mailing Address - Country:US
Mailing Address - Phone:954-571-9500
Mailing Address - Fax:954-571-9560
Practice Address - Street 1:3313 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-9423
Practice Address - Country:US
Practice Address - Phone:954-571-9500
Practice Address - Fax:954-571-9560
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250023207X00000X
FLME107403207X00000X
NC2010-01160207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917443Medicaid
NCNC0013AMedicare PIN
FLGI400ZMedicare PIN
NC5917443Medicaid