Provider Demographics
NPI:1881648665
Name:WU, JUSTIN JA-LI
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JA-LI
Last Name:WU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5266
Mailing Address - Country:US
Mailing Address - Phone:352-253-3333
Mailing Address - Fax:317-705-5047
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5266
Practice Address - Country:US
Practice Address - Phone:352-253-3333
Practice Address - Fax:317-705-5047
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1463802085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911117Medicaid
NC2248538Medicare ID - Type Unspecified
NC8911117Medicaid