1619916723 NPI number — DR. WOODROW WILSON JUSTICE O.D.

Table of content: DR. WOODROW WILSON JUSTICE O.D. (NPI 1619916723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619916723 NPI number — DR. WOODROW WILSON JUSTICE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTICE
Provider First Name:
WOODROW
Provider Middle Name:
WILSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619916723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 524
Provider Second Line Business Mailing Address:
215 S. WASHINGTON ST.
Provider Business Mailing Address City Name:
BOLIVAR
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38008-0524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-658-9522
Provider Business Mailing Address Fax Number:
731-658-9522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
358 NEW BYHALIA RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
COLLIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38017-3743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-853-8180
Provider Business Practice Location Address Fax Number:
901-853-1421
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  T875 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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