Provider Demographics
NPI:1770584377
Name:JUSTICE, JEFFREY LEONARD (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEONARD
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 E 7TH ST STE F
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2518
Practice Address - Country:US
Practice Address - Phone:260-266-8900
Practice Address - Fax:260-266-8935
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036727A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100081240Medicaid
MI103410325Medicaid
IN020027041OtherMEDICARE RAILROAD
OH0999728Medicaid
INB49293Medicare UPIN
OHJU4200012Medicare PIN
IN667640EMedicare PIN
IN100081240Medicaid
MI103410325Medicaid
IN260100FMedicare PIN
IN149110RMedicare PIN
OH4200011Medicare PIN