Healthcare Provider Details

I. General information

NPI: 1730574500
Provider Name (Legal Business Name): JUSTIN BROADHEAD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM ST # 7TH
MOBILE AL
36617-2238
US

IV. Provider business mailing address

429 PINEHURST DR
MERIDIAN MS
39305-9188
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7207
  • Fax:
Mailing address:
  • Phone: 601-227-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2178
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: