Healthcare Provider Details

I. General information

NPI: 1326198672
Provider Name (Legal Business Name): JUSTIN JOHN UPP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 HARTNESS RD
STATESVILLE NC
28677-3425
US

IV. Provider business mailing address

200 PROVIDENCE RD SUITE 101
CHARLOTTE NC
28207-1468
US

V. Phone/Fax

Practice location:
  • Phone: 704-873-5651
  • Fax: 704-749-5819
Mailing address:
  • Phone: 704-749-5800
  • Fax: 704-749-5819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2014-00034
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: