Provider Demographics
NPI:1023057098
Name:THULIN, JUSTIN F (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:F
Last Name:THULIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1151 E 3900 S
Mailing Address - Street 2:STE B259
Mailing Address - City:SALT LAKE CTY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1259
Mailing Address - Country:US
Mailing Address - Phone:801-266-7325
Mailing Address - Fax:801-281-2263
Practice Address - Street 1:1151 E 3900 S
Practice Address - Street 2:PARKVIEW BUILDING B 259
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1216
Practice Address - Country:US
Practice Address - Phone:801-266-7325
Practice Address - Fax:801-281-2263
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-10-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT3259971205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9311824424OtherTAX ID NUMBER
UT9311824424OtherTAX ID NUMBER