Basic Information
| Provider Information | |||||||||
| NPI: | 1093826125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTESEN | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1201 ALHAMBRA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167317775 | ||||||||
| FaxNumber: | 9167317785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G74319 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083X0100X | G73419 | CA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.