Provider Demographics
NPI:1447789888
Name:DOUGLAS, DUSTIN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N 21ST ST APT 139
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-5076
Mailing Address - Country:US
Mailing Address - Phone:702-955-0912
Mailing Address - Fax:
Practice Address - Street 1:50 N 21 ST #139
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101
Practice Address - Country:US
Practice Address - Phone:702-955-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No224ZR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantDriving and Community Mobility