Basic Information
| Provider Information | |||||||||
| NPI: | 1881648665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | JA-LI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522533333 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522533333 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | ME146380 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.