Doctor Name: | KELLY L DUSTIN |
NPI Number: | 1114957362 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DO |
License Number: | MR0875 |
Business Practice Address: | 1308 Bennett Ave Burley, ID - 833182665 |
Business Phone Number: | 2086787796 |
Business Fax Number: | 2087687799 |
Mailing Address: | 794 Eastland Dr, TWIN FALLS |
State: | ID |
Postal Code: | 833016856 |
Phone Number: | 2087343312 |
Fax Number: | 2087345036 |
NPI Enumeration Date: | 07/04/2006 |
NPI Last Update Date: | 11/26/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 390200000X |
License Number: | MR0875 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | ID |
Taxonomy Type: | Student, Health Care |
Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |