=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831163898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE R JUSTINIANO-AYALA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2006
-----------------------------------------------------
Last Update Date | 06/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 JENKINS RD
-----------------------------------------------------
City | ROSSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-866-5520
-----------------------------------------------------
Fax | 706-866-5502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13570 N MAIN ST
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30752-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-866-5520
-----------------------------------------------------
Fax | 706-866-5502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 46773
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------