Provider Demographics
NPI:1174713168
Name:HATA, JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11406 LOMA LINDA DR
Mailing Address - Street 2:#300
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-6277
Mailing Address - Fax:909-558-6278
Practice Address - Street 1:11406 LOMA LINDA DR # 300
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3711
Practice Address - Country:US
Practice Address - Phone:909-558-6277
Practice Address - Fax:909-558-6278
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA867282081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine