Basic Information
| Provider Information | |||||||||
| NPI: | 1194925743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228493 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 SOUTHERN BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555002873 | ||||||||
| FaxNumber: | 9372813992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101244227 | VA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | NOT YET ISSUED | VA | N | Allopathic & Osteopathic Physicians | Surgery | 208200000X | 0101244227 | VA | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0376539 | 05 | OH | MEDICAID |