Provider Demographics
NPI:1487820262
Name:POPE, DUSTIN LEE (OT)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:POPE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1608
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1608
Mailing Address - Country:US
Mailing Address - Phone:479-587-3130
Mailing Address - Fax:479-444-6942
Practice Address - Street 1:3317 N WIMBERLY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4056
Practice Address - Country:US
Practice Address - Phone:479-587-3117
Practice Address - Fax:479-444-6942
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2177225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5V0197318Medicare PIN
AR5V019C207Medicare PIN