Healthcare Provider Details

I. General information

NPI: 1508250622
Provider Name (Legal Business Name): JUSTIN MCCORMICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PLUM ST FL 5
NEW BRUNSWICK NJ
08901-2066
US

IV. Provider business mailing address

10 PLUM ST FL 5
NEW BRUNSWICK NJ
08901-2066
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-5530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA167071
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25MA11134900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: