Healthcare Provider Details

I. General information

NPI: 1639160203
Provider Name (Legal Business Name): RORY D JUSTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MOUNTAIN VIEW DR
KIMBALL TN
37347-5477
US

IV. Provider business mailing address

24 MOUNTAIN VIEW DR
KIMBALL TN
37347-5477
US

V. Phone/Fax

Practice location:
  • Phone: 423-942-9171
  • Fax: 423-942-9128
Mailing address:
  • Phone: 423-942-9171
  • Fax: 423-942-9128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD31741
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: