Healthcare Provider Details

I. General information

NPI: 1871932699
Provider Name (Legal Business Name): JUSTIN THOMAS HULL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N SANTIAM HWY
LEBANON OR
97355-4363
US

IV. Provider business mailing address

PO BOX 1193
CORVALLIS OR
97339-1193
US

V. Phone/Fax

Practice location:
  • Phone: 541-451-6479
  • Fax: 541-451-7085
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPG162468
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDO176931
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: