Provider Demographics
NPI:1437337094
Name:TIMOTHY JUSTICE MD PC
Entity type:Organization
Organization Name:TIMOTHY JUSTICE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-666-2095
Mailing Address - Street 1:425 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-7131
Mailing Address - Country:US
Mailing Address - Phone:303-666-2095
Mailing Address - Fax:303-666-1801
Practice Address - Street 1:425 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-7131
Practice Address - Country:US
Practice Address - Phone:303-666-2095
Practice Address - Fax:303-666-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01323328Medicaid
COC46801Medicare PIN
COC99713Medicare UPIN