Provider Demographics
NPI:1427212059
Name:SULAK, DUSTIN R (DO)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:R
Last Name:SULAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 U.S. ROUTE 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105
Mailing Address - Country:US
Mailing Address - Phone:207-482-0188
Mailing Address - Fax:888-642-8601
Practice Address - Street 1:964 WESTERN AVE.
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351
Practice Address - Country:US
Practice Address - Phone:207-512-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MET0861207Q00000X
MEDO2142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433021499Medicaid