Provider Demographics
NPI:1679924344
Name:MCJUNKINS, AUSTIN LEE ROACH (MD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:LEE ROACH
Last Name:MCJUNKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 LANGDON ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1614
Mailing Address - Country:US
Mailing Address - Phone:864-582-2411
Mailing Address - Fax:864-594-0040
Practice Address - Street 1:460 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1614
Practice Address - Country:US
Practice Address - Phone:864-582-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL39563208600000X
171000000X
NC2018-01199208600000X, 208D00000X
SC39563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No171000000XOther Service ProvidersMilitary Health Care Provider
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL39563OtherLIMITED LICENSE
SC39563OtherMEDICAL LICENSE