Healthcare Provider Details

I. General information

NPI: 1679890636
Provider Name (Legal Business Name): JUSTIN D WALTROUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8096 EDWIN RAYNOR BLVD STE C
PASADENA MD
21122-6837
US

IV. Provider business mailing address

3375 ELLICOTT CENTER DRIVE PO BOX 540
ELLICOTT CITY MD
21043
US

V. Phone/Fax

Practice location:
  • Phone: 443-702-2453
  • Fax: 443-702-2478
Mailing address:
  • Phone: 410-302-0561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberD77249
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: