Provider Demographics
NPI:1649273491
Name:JUSTICE, RAYMOND T (DPM)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:T
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000 DEPT 10
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:812-280-8620
Mailing Address - Fax:
Practice Address - Street 1:416 E COURT AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3414
Practice Address - Country:US
Practice Address - Phone:812-280-8620
Practice Address - Fax:812-820-8621
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000842A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000039643OtherANTHEM
IN213533OtherANTHEM
KY480026929OtherRAILROAD
1074442OtherPASSPORT
IN200144660BMedicaid
KY80002389Medicaid
2435167000OtherPASSPORT ADVANTAGE
KY80002389Medicaid
IN196200Medicare PIN
2435167000OtherPASSPORT ADVANTAGE
KY480026929OtherRAILROAD