Healthcare Provider Details

I. General information

NPI: 1558546663
Provider Name (Legal Business Name): JUSTIN PERSICO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9001
US

IV. Provider business mailing address

5520 PARK AVE
TRUMBULL CT
06611-3463
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-6737
  • Fax:
Mailing address:
  • Phone: 203-502-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number050598
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: