Provider Demographics
NPI:1790774420
Name:MAQUEIRA, JUSTO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTO
Middle Name:
Last Name:MAQUEIRA
Suffix:JR
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 1:103 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4501
Mailing Address - Country:US
Mailing Address - Phone:850-769-0338
Mailing Address - Fax:850-785-6088
Practice Address - Street 1:103 E 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4501
Practice Address - Country:US
Practice Address - Phone:850-769-0338
Practice Address - Fax:850-785-6088
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-15
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64912207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379881000Medicaid