Basic Information
| Provider Information | |||||||||
| NPI: | 1124480033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1600 22ND AVENUE | ||||||||
| Address2: | MEDICAL TOWERS 3, THIRD FLOOR, SUITE B | ||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017038370 | ||||||||
| FaxNumber: | 6017038397 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 22ND AVENUE | ||||||||
| Address2: | MEDICAL TOWERS 3, THIRD FLOOR, SUITE B | ||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017038370 | ||||||||
| FaxNumber: | 6017038397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25857 | MS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 07126570 | 05 | MS | MEDICAID |