Provider Demographics
NPI:1780661611
Name:JUSTO, MONA D (MD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:D
Last Name:JUSTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 MCADOO AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-2014
Mailing Address - Country:US
Mailing Address - Phone:201-600-1439
Mailing Address - Fax:201-451-5017
Practice Address - Street 1:540 E 11TH ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-2247
Practice Address - Country:US
Practice Address - Phone:570-752-6641
Practice Address - Fax:570-784-5730
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
WV20885208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2003463000Medicaid
WVJU4124101Medicare ID - Type Unspecified
WV2003463000Medicaid