Basic Information
Provider Information
NPI: 1003002148
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OWENS
FirstName: JUSTIN
MiddleName: MICHAEL
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 243 CURTISS RD
Address2: STE 100
City: BARKSDALE AFB
State: LA
PostalCode: 711102425
CountryCode: US
TelephoneNumber: 3184564318
FaxNumber: 3184568065
Practice Location
Address1: 243 CURTISS RD
Address2: STE 100
City: BARKSDALE AFB
State: LA
PostalCode: 711102425
CountryCode: US
TelephoneNumber: 3184564318
FaxNumber: 3184568065
Other Information
ProviderEnumerationDate: 09/21/2007
LastUpdateDate: 10/30/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2083A0100XMD.29091ALY Allopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine

No ID Information.


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