Provider Demographics
NPI:1952529828
Name:NORTHEIM, JUSTIN ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:NORTHEIM
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 1:9161 CEDAR RDG
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-4344
Mailing Address - Country:US
Mailing Address - Phone:952-818-4083
Mailing Address - Fax:
Practice Address - Street 1:3535 S INTERSTATE 35 E
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6850
Practice Address - Country:US
Practice Address - Phone:940-384-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51416207PE0004X
TXN8132207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00896830OtherRAILROAD
TX219337701Medicaid
TX219337702Medicaid
TXTXB132665Medicare PIN
TXP00896830OtherRAILROAD