Healthcare Provider Details

I. General information

NPI: 1629211891
Provider Name (Legal Business Name): JUSTIN SANDERS HALE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 CHALAN GUMA YUOS ST
TAMUNING GU
96913-3630
US

IV. Provider business mailing address

543 CHALAN GUMA YUOS ST
TAMUNING GU
96913-3630
US

V. Phone/Fax

Practice location:
  • Phone: 671-649-4764
  • Fax: 671-649-4765
Mailing address:
  • Phone: 671-649-4764
  • Fax: 671-649-4765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number161576
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number161576
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberM-1847
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: