Provider Demographics
NPI:1790721819
Name:JUSTICE, LARRY T (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:T
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 1:80 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6474
Mailing Address - Country:US
Mailing Address - Phone:865-482-4078
Mailing Address - Fax:865-482-4960
Practice Address - Street 1:80 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6474
Practice Address - Country:US
Practice Address - Phone:865-482-4078
Practice Address - Fax:865-482-4960
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40574207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3338151Medicaid
TN4125100OtherBCBST
7100065540OtherKYMEDICAID
TNQ009959Medicaid
TN3379860Medicaid
TN4125100OtherBCBST
33381512Medicare PIN
7100065540OtherKYMEDICAID
TN3379860Medicaid
TN3338151Medicaid