Provider Demographics
NPI:1649972654
Name:ALI, JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ALI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MYRTLE AVE
Mailing Address - Street 2:MAIL CODE: 21
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208
Mailing Address - Country:US
Mailing Address - Phone:518-264-2866
Mailing Address - Fax:
Practice Address - Street 1:391 MYRTLE AVE
Practice Address - Street 2:MAIL CODE: 21
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-264-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY64722390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program