Healthcare Provider Details

I. General information

NPI: 1083907836
Provider Name (Legal Business Name): JUSTIN MARGOLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF SURGERY HEALTH SCIENCES CENTER T19-090
STONY BROOK NY
11794-8191
US

IV. Provider business mailing address

419 SOUTH 'L' ST
TACOMA WA
98405
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2037
  • Fax: 631-444-8824
Mailing address:
  • Phone: 253-403-8410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD60998848
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: