Provider Demographics
NPI:1679599906
Name:JUSTICE, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:JUSTICE
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:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-0176
Mailing Address - Country:US
Mailing Address - Phone:304-792-7130
Mailing Address - Fax:304-792-7138
Practice Address - Street 1:ROUTE 10, THREE MILE CURVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601
Practice Address - Country:US
Practice Address - Phone:304-792-7130
Practice Address - Fax:304-792-7138
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV193062084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVG78380Medicare UPIN