Provider Demographics
NPI:1487624201
Name:JUSTICE, WAYNE P (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:P
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1003 COLLEGE BLVD W
Mailing Address - Street 2:STE 2
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1068
Mailing Address - Country:US
Mailing Address - Phone:850-678-0443
Mailing Address - Fax:850-678-7999
Practice Address - Street 1:1003 COLLEGE BLVD W
Practice Address - Street 2:STE 2
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1068
Practice Address - Country:US
Practice Address - Phone:850-678-0443
Practice Address - Fax:850-678-7999
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME83181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266324400Medicaid
FL7809271OtherAETNA
FL080190843OtherMEDICARE RAILROAD
FL05126OtherBCBS
FL7809271OtherAETNA
FL266324400Medicaid