Provider Demographics
NPI:1730470899
Name:CASEY, JUSTIN T (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:CASEY
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:39 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7531
Practice Address - Country:US
Practice Address - Phone:239-936-1616
Practice Address - Fax:239-936-0837
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126584207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018272400Medicaid
FLKQKBHOtherBCBS
FL1344406OtherWELLCARE MEDICARE/MEDICAID
FLP01716775OtherRR MEDICARE
FLP1043848OtherFREEDOM
FL8349059OtherCIGNA
FLP978488OtherOPTIMUM
FL1254617OtherWELLCARE HEALTHY KIDS
FL1344406OtherWELLCARE MEDICARE/MEDICAID