Provider Demographics
NPI:1922702786
Name:TSE, JUSTIN DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DAVID
Last Name:TSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3037
Mailing Address - Country:US
Mailing Address - Phone:916-781-1632
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3037
Practice Address - Country:US
Practice Address - Phone:916-781-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program