Provider Demographics
NPI:1477558708
Name:JUSTICE, KEITH MYRON (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MYRON
Last Name:JUSTICE
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 1:2460 OLD MOULTRIE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:904-563-1482
Mailing Address - Fax:
Practice Address - Street 1:2460 OLD MOULTRIE RD STE 4
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4198
Practice Address - Country:US
Practice Address - Phone:904-563-1482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 75770207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44678OtherBCBS
FL7174040OtherAETNA
FL255358900Medicaid
FL272323OtherAVMED
FLG78663OtherUPIN
FLP00189937Medicare PIN
FL44678OtherBCBS
FL255358900Medicaid
FLE1157XMedicare PIN