Provider Demographics
NPI:1568821163
Name:TEW, DUSTIN FERREL (DO)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:FERREL
Last Name:TEW
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 1:11929 BRIARLEAF WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-5254
Mailing Address - Country:US
Mailing Address - Phone:208-339-4239
Mailing Address - Fax:
Practice Address - Street 1:2265 E SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7598
Practice Address - Country:US
Practice Address - Phone:208-542-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A187662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology