Healthcare Provider Details

I. General information

NPI: 1104811041
Provider Name (Legal Business Name): JOHN C JUSTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N EISENHOWER AVE
MASON CITY IA
50401-1525
US

IV. Provider business mailing address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 641-422-7388
  • Fax: 641-422-5755
Mailing address:
  • Phone: 319-356-1474
  • Fax: 319-356-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18486
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0252577
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier43730
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: