Provider Demographics
NPI:1912326497
Name:THOTTAM, JUSTIN MATHEW (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MATHEW
Last Name:THOTTAM
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-3876
Mailing Address - Fax:
Practice Address - Street 1:6200 SUNSET DR STE 120
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4832
Practice Address - Country:US
Practice Address - Phone:786-596-3876
Practice Address - Fax:786-533-9989
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013312208100000X
390200000X
FLOS15910208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program