Provider Demographics
NPI:1215682943
Name:PALM, JUSTIN ELAN (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ELAN
Last Name:PALM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUILDING 99, UNIT 5024
Mailing Address - Street 2:MISAWA AIR BASE
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319
Mailing Address - Country:US
Mailing Address - Phone:017-677-6133
Mailing Address - Fax:
Practice Address - Street 1:MISAWA AIR BASE 35TH MDG FLIGHT
Practice Address - Street 2:BUILDING 99, UNIT 5024
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319
Practice Address - Country:US
Practice Address - Phone:017-677-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0071574208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty