Healthcare Provider Details

I. General information

NPI: 1093826125
Provider Name (Legal Business Name): LYLE RICHARD JUSTESEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ALHAMBRA BLVD SUITE 210
SACRAMENTO CA
95816-5238
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-731-7775
  • Fax: 916-731-7785
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG74319
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberG73419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: