Healthcare Provider Details

I. General information

NPI: 1477558708
Provider Name (Legal Business Name): KEITH MYRON JUSTICE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 OLD MOULTRIE RD STE 4
ST AUGUSTINE FL
32086-4198
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 4
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 904-563-1482
  • Fax:
Mailing address:
  • Phone: 904-563-1482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME 75770
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: