Healthcare Provider Details

I. General information

NPI: 1689179657
Provider Name (Legal Business Name): JUSTIN JONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 WHITESBURG DR SW STE 200
HUNTSVILLE AL
35802-1681
US

IV. Provider business mailing address

4704 WHITESBURG DR SW STE 200
HUNTSVILLE AL
35802-1681
US

V. Phone/Fax

Practice location:
  • Phone: 256-880-4510
  • Fax: 256-880-4512
Mailing address:
  • Phone: 256-880-4510
  • Fax: 256-880-4512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD.46459
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: