Healthcare Provider Details

I. General information

NPI: 1033586912
Provider Name (Legal Business Name): COURTNEY ELIZABETH JUSTICE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 BETHEL RD
COLUMBUS OH
43220-2217
US

IV. Provider business mailing address

308 ELIZABETH LN
WAVERLY OH
45690-1168
US

V. Phone/Fax

Practice location:
  • Phone: 614-326-0761
  • Fax:
Mailing address:
  • Phone: 740-222-8794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.6382
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: