Healthcare Provider Details

I. General information

NPI: 1164715587
Provider Name (Legal Business Name): JUSTIN LAMB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 07/10/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MDG 4102 PINION DR
USAFA CO
80840
US

IV. Provider business mailing address

PSC 41 BOX 193
APO AE
09464-0002
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101252628
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: