Provider Demographics
NPI:1528378502
Name:DUSLAK, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DUSLAK
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 1:2133 W LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3707
Mailing Address - Country:US
Mailing Address - Phone:312-746-4664
Mailing Address - Fax:312-746-6526
Practice Address - Street 1:2133 W LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3707
Practice Address - Country:US
Practice Address - Phone:312-746-4664
Practice Address - Fax:312-746-6526
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRNIT20042042083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILRNIT20041204204OtherRANDON MEASUREMENT TECH