Provider Demographics
NPI:1144373804
Name:DAUGHTRY, JUSTIN W (PT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:W
Last Name:DAUGHTRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3390 MT .DIABLO BOULEVARD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-1223
Mailing Address - Country:US
Mailing Address - Phone:925-284-6150
Mailing Address - Fax:925-284-6155
Practice Address - Street 1:3390 MT DIABLO BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4006
Practice Address - Country:US
Practice Address - Phone:925-284-6155
Practice Address - Fax:925-284-6155
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT26243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056674Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER