Healthcare Provider Details

I. General information

NPI: 1588896708
Provider Name (Legal Business Name): JUSTIN ANTHONY CLASSIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16303 HORACE HARDING EXPY 4TH FLOOR
FRESH MEADOWS NY
11365-1454
US

IV. Provider business mailing address

5645 MAIN ST 4TH FLOOR SOUTH
FLUSHING NY
11355-5045
US

V. Phone/Fax

Practice location:
  • Phone: 866-670-6824
  • Fax: 718-670-2249
Mailing address:
  • Phone: 866-670-6824
  • Fax: 718-670-2249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number093034
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number255812
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: