Provider Demographics
NPI:1962750323
Name:LAW, JUSTIN MCIVOR (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MCIVOR
Last Name:LAW
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 1:1400 COLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-0001
Mailing Address - Country:US
Mailing Address - Phone:478-301-2700
Mailing Address - Fax:
Practice Address - Street 1:1400 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-0001
Practice Address - Country:US
Practice Address - Phone:478-301-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076754207Q00000X
TN72978207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine