Healthcare Provider Details

I. General information

NPI: 1255415782
Provider Name (Legal Business Name): JUSTIN C HUANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W LOSEY ST
SCOTT AFB IL
62225-5250
US

IV. Provider business mailing address

1104 HIGHTOWER PLACE DR
O FALLON IL
62269-7069
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-5203
  • Fax:
Mailing address:
  • Phone: 77-688-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101240627
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: