Provider Demographics
NPI:1184886822
Name:VINING, JUSTIN MACKENZIE (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MACKENZIE
Last Name:VINING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MAC
Other - Middle Name:
Other - Last Name:VINING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 746645
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6645
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:2418 E PLAZA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5301
Practice Address - Country:US
Practice Address - Phone:850-629-4861
Practice Address - Fax:850-629-4859
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002992208000000X
FLME126004208000000X, 2080P0202X
GA0666642080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
066664OtherGA LICENSES
GAFV4526236OtherGA DEA