Provider Demographics
NPI:1720156136
Name:JUSTINO, EDMUNDO SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:EDMUNDO
Middle Name:SAMUEL
Last Name:JUSTINO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:810 AINSWORTH DR STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1612
Practice Address - Country:US
Practice Address - Phone:928-771-5548
Practice Address - Fax:928-771-5549
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11931207RG0100X
AZ60368207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215032801Medicaid
TXTXB107550OtherMEDICARE PTAN
AZ60368OtherMEDICAL LICENSE
AZ007145Medicaid
AZ60368OtherMEDICAL LICENSE