Healthcare Provider Details

I. General information

NPI: 1053338699
Provider Name (Legal Business Name): DAVID LAVERN JUSTIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2246 GEORGE WASHINGTON MEMORIAL HWY
HAYES VA
23072-3559
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD SUITE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 804-684-5565
  • Fax: 804-684-5863
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101238293
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: