Healthcare Provider Details

I. General information

NPI: 1326627688
Provider Name (Legal Business Name): JUSTIN THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

1275 YORK AVE
NEW YORK NY
10065-6007
US

V. Phone/Fax

Practice location:
  • Phone: 347-798-9213
  • Fax:
Mailing address:
  • Phone: 631-816-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number345598
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: