Provider Demographics
NPI:1568959286
Name:TALIAFERRO, DUSTIN LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:LEE
Last Name:TALIAFERRO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2180 BENNETT AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6925
Mailing Address - Country:US
Mailing Address - Phone:903-343-3345
Mailing Address - Fax:
Practice Address - Street 1:6451 BRENTWOOD STAIR RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-3200
Practice Address - Country:US
Practice Address - Phone:817-496-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS3466207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program