Provider Demographics
NPI:1386938777
Name:MAXWELL, JUSTIN EVAN (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:EVAN
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:4730 S FORT APACHE RD STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7959
Practice Address - Country:US
Practice Address - Phone:702-940-1570
Practice Address - Fax:702-940-1571
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDO1829OtherSTATE LICENSE
NV1386938777Medicaid