Provider Demographics
NPI:1811552771
Name:CHARLES, JUSTIN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALEXANDER
Last Name:CHARLES
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 1:9500 GILMAN DRIVE
Mailing Address - Street 2:MC 0965
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-3220
Mailing Address - Country:US
Mailing Address - Phone:858-822-4434
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR # MC0965
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093
Practice Address - Country:US
Practice Address - Phone:858-822-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180599390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program