Provider Demographics
NPI:1265564009
Name:WHEELER, JUSTIN DANIEL (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:WHEELER
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 1:1620 COOPER POINT RD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5736
Mailing Address - Country:US
Mailing Address - Phone:360-486-6710
Mailing Address - Fax:360-705-0269
Practice Address - Street 1:1620 COOPER POINT RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5736
Practice Address - Country:US
Practice Address - Phone:360-486-6710
Practice Address - Fax:360-705-0269
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60889819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98404253Medicaid