MEDICARE: DR. JUSTIN E SANDHOLM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2876	CO

General Provider Information

NPI Number	:	1023161791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN E SANDHOLM O.D.

Provider Business Mailing Address
First Line	:	42D MEDICAL GROUP
Second Line	:	300 SOUTH TWINING STREET, BLDG 760
City	:	MONTGOMERY
State	:	AL
Zip	:	36112-6027
Country	:	US
Telephone Number	:	334-953-5200
Fax Number	:

Provider Business Practice Location Address
First Line	:	42D MEDICAL GROUP
Second Line	:	300 SOUTH TWINING STREET, BLDG 760
City	:	MONTGOMERY
State	:	AL
Zip	:	36112-6027
Country	:	US
Telephone Number	:	334-953-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	08/18/2025

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