Provider Demographics
NPI:1912298316
Name:SKWERES, JUSTIN WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WAYNE
Last Name:SKWERES
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:PO BOX 3488, DEPT 05-045
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:844-699-0011
Mailing Address - Fax:
Practice Address - Street 1:3001 S HANOVER ST
Practice Address - Street 2:DEPT OF INTERNAL MEDICINE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1233
Practice Address - Country:US
Practice Address - Phone:410-350-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.2071142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program