Provider Demographics
NPI:1700170636
Name:STONE, JUSTIN MAXWELL (CP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MAXWELL
Last Name:STONE
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 E 19TH ST
Mailing Address - Street 2:SUITE 604
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5437
Mailing Address - Country:US
Mailing Address - Phone:918-549-5888
Mailing Address - Fax:918-744-3562
Practice Address - Street 1:1725 E 19TH ST
Practice Address - Street 2:SUITE 604
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5437
Practice Address - Country:US
Practice Address - Phone:918-549-5888
Practice Address - Fax:918-744-3562
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist