Provider Demographics
NPI:1831163898
Name:JUSTINIANO-AYALA, JOSE R (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:JUSTINIANO-AYALA
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 1:13570 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-2012
Mailing Address - Country:US
Mailing Address - Phone:706-866-5520
Mailing Address - Fax:706-866-5502
Practice Address - Street 1:205 JENKINS RD
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741
Practice Address - Country:US
Practice Address - Phone:706-866-5520
Practice Address - Fax:706-866-5502
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147280AMedicaid
GA111028OtherMEDICARE OSCAR/CERTIFICATION
GA111985OtherMEDICARE OSCAR/CERTIFICATION
GA003151883AMedicaid
GA000211956AMedicaid
GA000211956CMedicaid
GA003138289AMedicaid
GA111982OtherMEDICARE/OSCAR/CERTIFICATION