Provider Demographics
NPI:1093699076
Name:BROGDON, JUSTIN DAKOTA (DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAKOTA
Last Name:BROGDON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 E OAKLAND AVE APT D39
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-7801
Mailing Address - Country:US
Mailing Address - Phone:985-951-0412
Mailing Address - Fax:
Practice Address - Street 1:LAMONT ST &, VETERANS WAY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist