Provider Demographics
NPI:1699923516
Name:NEEDHAM, JUSTIN DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DANIEL
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 1201
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4550
Mailing Address - Country:US
Mailing Address - Phone:678-381-2020
Mailing Address - Fax:678-381-2015
Practice Address - Street 1:1995 MALL OF GEORGIA BLVD STE A
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519
Practice Address - Country:US
Practice Address - Phone:678-381-2020
Practice Address - Fax:678-381-2015
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24771207W00000X, 208D00000X
GA79768207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UPIN: VAD000OtherUPIN