Provider Demographics
NPI:1982676664
Name:PHILLPOTT, JUSTIN WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WESLEY
Last Name:PHILLPOTT
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 1:2055 NORMANDIE DR
Mailing Address - Street 2:108
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2732
Mailing Address - Country:US
Mailing Address - Phone:334-288-4624
Mailing Address - Fax:334-280-3628
Practice Address - Street 1:2055 NORMANDIE DR
Practice Address - Street 2:108
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2732
Practice Address - Country:US
Practice Address - Phone:334-288-4624
Practice Address - Fax:334-280-3628
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000263332085R0202X, 2085R0204X
FLME765502085R0202X, 2085R0204X
TXJ87152085R0202X, 2085R0204X
GA0538052085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL107041Medicaid
AL108373Medicaid
AL107043Medicaid
AL108074Medicaid
000058867Medicare PIN
051526598Medicare PIN
000058866Medicare PIN
AL108074Medicaid
AL107043Medicaid
G41129Medicare UPIN
051504364Medicare PIN