Provider Demographics
NPI:1699923516
Name:NEEDHAM, JUSTIN DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DANIEL
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1915 S 17TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6682
Mailing Address - Country:US
Mailing Address - Phone:910-769-4590
Mailing Address - Fax:910-769-4563
Practice Address - Street 1:1915 S 17TH ST STE 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6682
Practice Address - Country:US
Practice Address - Phone:910-769-4590
Practice Address - Fax:910-769-4653
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24771207W00000X, 208D00000X
GA79768207W00000X
NC2023-03120207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UPIN: VAD000OtherUPIN