Healthcare Provider Details

I. General information

NPI: 1386490654
Provider Name (Legal Business Name): JUSTIN E STUDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 3RD ST
MANSFIELD OH
44906-2633
US

IV. Provider business mailing address

600 W 3RD ST
MANSFIELD OH
44906-2633
US

V. Phone/Fax

Practice location:
  • Phone: 419-522-6191
  • Fax: 419-526-7939
Mailing address:
  • Phone: 440-935-5296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009104RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: