Healthcare Provider Details

I. General information

NPI: 1710366851
Provider Name (Legal Business Name): JUSTIN EALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BANNER UNIVERSITY MEDICAL CENTER 1501 N AVE
TUCSON AZ
85724-0001
US

IV. Provider business mailing address

BANNER UNIVERSITY MEDICAL CENTER 1501 N AVE
TUCSON AZ
85724-0001
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-7233
  • Fax:
Mailing address:
  • Phone: 520-626-7233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR75053
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: