Provider Demographics
NPI:1407187875
Name:ROSENBURG, DUSTIN CLARK (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:CLARK
Last Name:ROSENBURG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 MARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2644
Mailing Address - Country:US
Mailing Address - Phone:618-931-3100
Mailing Address - Fax:618-931-3123
Practice Address - Street 1:4917 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-2644
Practice Address - Country:US
Practice Address - Phone:618-931-3100
Practice Address - Fax:618-931-3123
Is Sole Proprietor?:No
Enumeration Date:2010-01-24
Last Update Date:2010-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor