Provider Demographics
NPI:1578069639
Name:DUSTO, NATHANIEL LOOMIS (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:LOOMIS
Last Name:DUSTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 THE CITY DR S BLDG 53
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3201
Mailing Address - Country:US
Mailing Address - Phone:714-456-6668
Mailing Address - Fax:714-456-6557
Practice Address - Street 1:101 THE CITY DR S BLDG 53
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-6668
Practice Address - Fax:714-456-6557
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program