Provider Demographics
NPI:1346553807
Name:FULLAWAY, DUSTIN C (PT)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:C
Last Name:FULLAWAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 MILLBURN AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1847
Mailing Address - Country:US
Mailing Address - Phone:973-467-7976
Mailing Address - Fax:973-467-7971
Practice Address - Street 1:1325 WARREN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-2566
Practice Address - Country:US
Practice Address - Phone:732-449-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01355900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist