Basic Information
Provider Information | |||||||||
NPI: | 1629164678 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLOYD | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210W MCKINLEY AVE 1 | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | IL | ||||||||
PostalCode: | 625265858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2178779442 | ||||||||
FaxNumber: | 2178766606 | ||||||||
Practice Location | |||||||||
Address1: | 13 WOLF CREEK DR | ||||||||
Address2: | SUITE 1 | ||||||||
City: | SWANSEA | ||||||||
State: | IL | ||||||||
PostalCode: | 622262367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184167970 | ||||||||
FaxNumber: | 6184167971 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 09/19/2016 | ||||||||
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 | 207RX0202X | 2001014924 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 036112641 | 05 | IL |   | MEDICAID |