Provider Demographics
NPI:1942697313
Name:HART, JUSTIN WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WAYNE
Last Name:HART
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 1:13450 N MERIDIAN ST STE 145
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13450 N MERIDIAN ST STE 145
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1484
Practice Address - Country:US
Practice Address - Phone:317-338-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021522208600000X
IN02006776A2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery