Basic Information
| Provider Information | |||||||||
| NPI: | 1417683996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTIS | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | MADISON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25434 HENRYS POINT LN | ||||||||
| Address2: | |||||||||
| City: | ACCOMAC | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577099737 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 17TH ST NW STE 400 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200062507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023317566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2022 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2869 | MD | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 0618003148 | VA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OP2000539 | DC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.