Basic Information
Provider Information | |||||||||
NPI: | 1063825693 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALPOLE | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2643 PATTERSON RD STE 401 | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815061937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702983884 | ||||||||
FaxNumber: | 3703720995 | ||||||||
Practice Location | |||||||||
Address1: | 2643 PATTERSON RD STE 401 | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815061937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702983884 | ||||||||
FaxNumber: | 3703720995 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2014 | ||||||||
LastUpdateDate: | 09/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | R10054 | IA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | DR.0061901 | CO | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | R10054 | IA | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | DR.0061901 | CO | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0129X | R10054 | IA | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | DR.0061901 | CO | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | R10054 | IA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.