Provider Demographics
NPI:1023161791
Name:SANDHOLM, JUSTIN E (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:E
Last Name:SANDHOLM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42D MEDICAL GROUP
Mailing Address - Street 2:300 SOUTH TWINING STREET, BLDG 760
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36112-6027
Mailing Address - Country:US
Mailing Address - Phone:334-953-5200
Mailing Address - Fax:
Practice Address - Street 1:42D MEDICAL GROUP
Practice Address - Street 2:300 SOUTH TWINING STREET, BLDG 760
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:334-953-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91589Medicare UPIN