Provider Demographics
NPI:1821300492
Name:ALEXANDER, JUSTIN JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JACOB
Last Name:ALEXANDER
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 1:1 GLENLAKE PKWY
Mailing Address - Street 2:STE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3448
Mailing Address - Country:US
Mailing Address - Phone:205-427-4375
Mailing Address - Fax:
Practice Address - Street 1:1 GLENLAKE PKWY STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3496
Practice Address - Country:US
Practice Address - Phone:205-427-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014 - 01069208100000X
GA74102208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003164709BMedicaid
GA003164709CMedicaid
GA003164709AMedicaid