Healthcare Provider Details

I. General information

NPI: 1275546467
Provider Name (Legal Business Name): CHRISTOPHER JAMES JUSTINICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 IRVING AVE SUITE 504
SYRACUSE NY
13210
US

IV. Provider business mailing address

251 SALINA MEADOWS PKWY SUITE 100
SYRACUSE NY
13212-4516
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-8444
  • Fax: 315-464-8445
Mailing address:
  • Phone: 315-464-2000
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number52412
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number238439
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: