Healthcare Provider Details

I. General information

NPI: 1831163898
Provider Name (Legal Business Name): JOSE R JUSTINIANO-AYALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 JENKINS RD
ROSSVILLE GA
30741
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-866-5520
  • Fax: 706-866-5502
Mailing address:
  • Phone: 706-866-5520
  • Fax: 706-866-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46773
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: