Provider Demographics
NPI:1841217510
Name:JUSTESEN, CHAD R (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:R
Last Name:JUSTESEN
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 1:700 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1802
Mailing Address - Country:US
Mailing Address - Phone:701-234-4023
Mailing Address - Fax:701-234-4050
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1802
Practice Address - Country:US
Practice Address - Phone:701-234-4023
Practice Address - Fax:701-234-4050
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9230207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN388675100Medicaid
ND12073Medicaid
MN388675100Medicaid
H26813Medicare UPIN