Basic Information
Provider Information | |||||||||
NPI: | 1568720167 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUNSUCKER | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | TODD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 STADIUM DR | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265067911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045984850 | ||||||||
FaxNumber: | 3045984871 | ||||||||
Practice Location | |||||||||
Address1: | 1651 SE TIFFANY AVE | ||||||||
Address2: |   | ||||||||
City: | PORT SAINT LUCIE | ||||||||
State: | FL | ||||||||
PostalCode: | 349527564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7723981800 | ||||||||
FaxNumber: | 7723981815 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2012 | ||||||||
LastUpdateDate: | 10/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 26043 | WV | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 142430 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.