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General NPI Number Information
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NPI Number | 1730574500
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Entity Type | Individual
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Provider Name | JUSTIN BROADHEAD DO
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Gender | Male
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Dates
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Enumeration Date | 03/30/2015
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Last Update Date | 04/07/2022
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Provider Practice Location Address
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Address Line | 2451 FILLINGIM ST # 7TH
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City | MOBILE
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State | AL
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Zip | 36617-2238
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Country | US
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Telephone | 251-471-7207
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Fax |
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Provider Business Mailing Address
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Address Line | 429 PINEHURST DR
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City | MERIDIAN
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State | MS
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Zip | 39305-9188
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Country | US
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Telephone | 601-227-8105
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 2178
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License Number State | AL
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