Provider Demographics
NPI:1871818195
Name:LIST, JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LIST
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 1:125 WORTH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4006
Mailing Address - Country:US
Mailing Address - Phone:212-323-3079
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine